Organization
GENESIS KETAMINE CENTERS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. KELLY SHAW (PRACTICE MANAGER)
(267) 361-0315
Entity
Organization
Contact information
Practice address
1 BALA AVE STE 418, BALA CYNWYD, PA 19004-3207
(267) 361-0315
Mailing address
1 BALA AVE STE 418, BALA CYNWYD, PA 19004-3207
(267) 361-0315
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
—
—
261QM1300X
Multi-Specialty Clinic/Center
—
—
Other
Enumeration date
02/09/2023
Last updated
02/09/2023
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