Basic Information
| Provider Information | |||||||||
| NPI: | 1699084046 | ||||||||
| 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 PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JERRERSON ST | ||||||||
| Address2: | KAISER PERMANENTEATTN:SANJAY MATHUR | ||||||||
| City: | ROCVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208504908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018167446 | ||||||||
| FaxNumber: | 3018167170 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 2ND ST NE | ||||||||
| Address2: | SUITE L18 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200024308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023463300 | ||||||||
| FaxNumber: | 2023463301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2010 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | KEENAN | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PROVIDER OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3018166321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KAISER FOUNDATION HEALTH PLAN OF THE MID ATLANTIC STATES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPC | ||||||||
| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336M0003X | Y | Suppliers | Pharmacy | Managed Care Organization Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 410092 | 01 | DC | MEDICARE GROUP ID | OTHER |