Healthcare Provider Details

I. General information

NPI: 1366171720
Provider Name (Legal Business Name): BALTIMORE KETAMINE CLINIC EASTERN SHORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2324 N ZION RD STE 113
SALISBURY MD
21801-2576
US

IV. Provider business mailing address

2324 N ZION RD STE 113
SALISBURY MD
21801-2576
US

V. Phone/Fax

Practice location:
  • Phone: 410-870-5482
  • Fax: 410-628-1212
Mailing address:
  • Phone: 410-870-5482
  • Fax: 410-628-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: IVANA MITIC
Title or Position: OWNER
Credential: CRNP-PMH, CRNA
Phone: 713-412-3462