Provider Demographics
NPI:1073892113
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:KAISER PERMANENTE CAPITOL HILL MEDICAL CENTER AMBULATORY SURGERY CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDEE
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:KAISER PERMANENTE ATTN: JUDY OWITI, PROVIDER AFFAIRS 2E
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6513
Mailing Address - Fax:301-816-7170
Practice Address - Street 1:700 2ND ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-8100
Practice Address - Country:US
Practice Address - Phone:202-346-3825
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:2011-08-08
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC410092Medicare PIN