Provider Demographics
NPI:1003116534
Name:KAISER PERMANENTE
Entity Type:Organization
Organization Name:KAISER PERMANENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:RENA
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:301-702-6235
Mailing Address - Street 1:6104 OLD BRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-2518
Mailing Address - Country:US
Mailing Address - Phone:301-702-6235
Mailing Address - Fax:301-702-6366
Practice Address - Street 1:6104 OLD BRANCH AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-2518
Practice Address - Country:US
Practice Address - Phone:301-702-6235
Practice Address - Fax:301-702-6366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR096203302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization