Provider Demographics
NPI:1013526276
Name:KETAMINE INSTITUTE OF MICHIGAN
Entity Type:Organization
Organization Name:KETAMINE INSTITUTE OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CRNA
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:KLYDER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:734-731-9500
Mailing Address - Street 1:98 WINCHESTER ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-1957
Mailing Address - Country:US
Mailing Address - Phone:734-605-8500
Mailing Address - Fax:
Practice Address - Street 1:98 WINCHESTER ST STE 100
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-1957
Practice Address - Country:US
Practice Address - Phone:734-605-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Multi-Specialty