Provider Demographics
NPI: | 1073678637 |
---|---|
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: | TYSONS CORNER MEDICAL CENTER AMBULATORY SURGERY CENTER |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CHIEF FINANCIAL OFFICER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DEANNE |
Authorized Official - Middle Name: | G |
Authorized Official - Last Name: | PETERSEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 301-816-5760 |
Mailing Address - Street 1: | 2101 E JEFFERSON ST |
Mailing Address - Street 2: | 3 WEST KAISER PERMANENTE PROVIDER OPERATIONS |
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: | 8008 WESTPARK DR |
Practice Address - Street 2: | |
Practice Address - City: | MC LEAN |
Practice Address - State: | VA |
Practice Address - Zip Code: | 22102-3109 |
Practice Address - Country: | US |
Practice Address - Phone: | 703-490-8400 |
Practice Address - Fax: | |
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: | 2006-12-26 |
Last Update Date: | 2021-12-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 302R00000X | Managed Care Organizations | Health Maintenance Organization | ||
Yes | 261QA1903X | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207XS0117X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | Group - Multi-Specialty |
No | 208200000X | Allopathic & Osteopathic Physicians | Plastic Surgery | Group - Multi-Specialty | |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
No | 261QE0800X | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
A00073 | Medicare ID - Type Unspecified |