Provider Demographics
NPI:1699897629
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:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNE
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-816-5760
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE ATTN: SANJAY MATHUR, DATA MGMT 3 WEST
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-7446
Mailing Address - Fax:301-816-7170
Practice Address - Street 1:6111 EXECUTIVE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3911
Practice Address - Country:US
Practice Address - Phone:301-255-4000
Practice Address - Fax:301-816-7170
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:2007-04-03
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD410092Medicare PIN
410092Medicare ID - Type UnspecifiedMEDICARE GROUP ID
DC410092Medicare PIN