Basic Information
| Provider Information | |||||||||
| NPI: | 1497023188 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. | ||||||||
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| OtherOrganizationName: | KAISER PERMANENTE GAITHERSBURG MEDICAL CENTER AMBULATORY SURGERY CTR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON ST | ||||||||
| Address2: | PROVIDER OPERATIONS, ATTN: JUDY OWITI, 3W | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018166513 | ||||||||
| FaxNumber: | 3018167170 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 WATKINS MILL RD | ||||||||
| Address2: | |||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208793323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406324150 | ||||||||
| FaxNumber: | 2406324151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2011 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | PETERSEN | ||||||||
| AuthorizedOfficialFirstName: | ANDEE | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3018165760 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 410092 | 01 | MD | MEDICARE GROUP ID | OTHER |