Basic Information
| Provider Information | |||||||||
| NPI: | 1154622900 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF THE MID ATLANTIC STATES, INC | ||||||||
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| OtherOrganizationName: | KAISER PERMANENTE CAPITOL HILL DIALYSIS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101E JEFFERSON ST | ||||||||
| Address2: | 2 EAST KAISER PERMANENTE ATTN:SANJAY MATHUR | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208504908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018167446 | ||||||||
| FaxNumber: | 3018167170 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 2ND ST NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200024308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2029895100 | ||||||||
| FaxNumber: | 3018167170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2010 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORAN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | SENOR BUSINESS &TECHNOLOGY CONSULT | ||||||||
| AuthorizedOfficialTelephone: | 3018165832 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KAISER FOUNDATION HEALTH PLAN OF THE MID ATLANTIC STATES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BD1200X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Dialysis Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 410092 | 01 | MD | MEDICARE GROUP ID | OTHER |