Basic Information
| Provider Information | |||||||||
| NPI: | 1730254681 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF THE MID ATLANTIC STATES,INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | KAISER PERMANENTE DATA MANAGEMENT DEPARTMENT | ||||||||
| Address2: | 2101 E JEFFERSON STREET 3 WEST ATTENTION SANJAY MATHUR | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018167448 | ||||||||
| FaxNumber: | 3018167170 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 EAST JEFFERSON STREET | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018167446 | ||||||||
| FaxNumber: | 3018167170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | ANDEE | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF 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 | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
ID Information
| ID | Type | State | Issuer | Description | 306728 | 01 | MD | MEDICARE GROUP ID | OTHER | 410092 | 01 | DC | MEDICARE GROUP ID | OTHER | K679 | 01 | MD | MEDICARE GROUP ID | OTHER | A00073 | 01 | VA | MEDICARE GROUP ID | OTHER | C08232 | 01 | VA | MEDICARE GROUP ID | OTHER | G01288 | 01 | MD | MEDICARE GROUP ID | OTHER | S883 | 01 | MD | MEDICARE GROUP ID | OTHER |