Provider Demographics
NPI:1699084046
Name:KAISER FOUNDATION HEALTH PLAN OF THE MID ATLANTIC STATES, INC
Entity type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF THE MID ATLANTIC STATES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PROVIDER OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:KEENAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:301-816-6321
Mailing Address - Street 1:2101 E JERRERSON ST
Mailing Address - Street 2:KAISER PERMANENTEATTN:SANJAY MATHUR
Mailing Address - City:ROCVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-7446
Mailing Address - Fax:301-816-7170
Practice Address - Street 1:700 2ND ST NE
Practice Address - Street 2:SUITE L18
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4308
Practice Address - Country:US
Practice Address - Phone:202-346-3300
Practice Address - Fax:202-346-3301
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KAISER FOUNDATION HEALTH PLAN OF THE MID ATLANTIC STATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-04
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC410092OtherMEDICARE GROUP ID