Basic Information
| Provider Information | |||||||||
| NPI: | 1568520070 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KAISER FOUNDATION HEALTH PLAN MID ATLANTIC STATES | ||||||||
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| OtherOrganizationName: | PENDERBROOK MEDICAL CENTER LABORATORY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON STREET 3 WEST | ||||||||
| Address2: | KAISER PERMANENTE DATA MANAGEMENT DEPARTMENT | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018167446 | ||||||||
| FaxNumber: | 3018167170 | ||||||||
| Practice Location | |||||||||
| Address1: | 12011 LEE JACKSON HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220333310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032573050 | ||||||||
| FaxNumber: | 7032573042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | PETERSEN | ||||||||
| AuthorizedOfficialFirstName: | ANDEE | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CHEIF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3018165760 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | CPA MBA | ||||||||
| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.