Basic Information
| Provider Information | |||||||||
| NPI: | 1588903991 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC | ||||||||
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| OtherOrganizationName: | LARGO PERITONEAL DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018167142 | ||||||||
| FaxNumber: | 3018167353 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 MERCANTILE LN | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207745374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016185500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2013 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAWES | ||||||||
| AuthorizedOfficialFirstName: | GLEN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3018165760 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.