Basic Information
| Provider Information | |||||||||
| NPI: | 1881849255 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES,INC | ||||||||
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| OtherOrganizationName: | FREDERICKSBURG MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 EAST JEFFERSON ST | ||||||||
| Address2: | KAISER PERMANENTE DATA MANAGEMT DEPT.ATTN:SANJAY MATHUR | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018167446 | ||||||||
| FaxNumber: | 3018167170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224018428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403683700 | ||||||||
| FaxNumber: | 3018167170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2008 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | PETERSEN | ||||||||
| AuthorizedOfficialFirstName: | ANDEE | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHEIF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3018165760 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES,INC | ||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| 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 | C08232 | 01 | VA | MEDICARE GROUP ID | OTHER |