Basic Information
| Provider Information | |||||||||
| NPI: | 1114048295 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES,INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PENDERBROOK MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018167446 | ||||||||
| FaxNumber: | 3018167170 | ||||||||
| Practice Location | |||||||||
| Address1: | 12011 LEE JACKSON MEMORIAL HWY | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220333310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033835400 | ||||||||
| FaxNumber: | 7033835404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETERSEN | ||||||||
| AuthorizedOfficialFirstName: | ANDEE | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHEIF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3018165760 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES,INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA, MBA | ||||||||
| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.