Basic Information
| Provider Information | |||||||||
| NPI: | 1710945969 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAWAII PERMANENTE MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3288 MOANALUA RD | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968191469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084320000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3288 MOANALUA RD | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968191469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084320000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | STEFANELLI | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST. MED DIRECTOR BUSINESS SVCS | ||||||||
| AuthorizedOfficialTelephone: | 8084320000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
ID Information
| ID | Type | State | Issuer | Description | 00B000916-3 | 01 | HI | HMSA PROVIDER NUMBER | OTHER |