Basic Information
| Provider Information | |||||||||
| NPI: | 1407157597 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF THE MID ATLANTIC STATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6104 OLD BRANCH AVE | ||||||||
| Address2: | |||||||||
| City: | TEMPLE HILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207482518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017026109 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6104 OLD BRANCH AVE | ||||||||
| Address2: | |||||||||
| City: | TEMPLE HILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207482518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017026109 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2010 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | CROZIER | ||||||||
| AuthorizedOfficialFirstName: | LARA | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3018162424 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | R094722 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.