Provider Demographics
NPI:1083002315
Name:KAISER PERMANENTE
Entity Type:Organization
Organization Name:KAISER PERMANENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT ANALST
Authorized Official - Prefix:MS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PIETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-444-3522
Mailing Address - Street 1:111 SMITH RANCH ROAD
Mailing Address - Street 2:KAISER PERMANENTE
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903
Mailing Address - Country:US
Mailing Address - Phone:415-444-3522
Mailing Address - Fax:415-491-3028
Practice Address - Street 1:111 SMITH RANCH ROAD
Practice Address - Street 2:KAISER PERMANENTE
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903
Practice Address - Country:US
Practice Address - Phone:415-444-3522
Practice Address - Fax:415-491-3028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS14720273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
1639252604Medicare Oscar/Certification
CA1235226531Medicare NSC
CA1336222397Medicare NSC
CA1841373800Medicare NSC
CA1073606299Medicare NSC
CA1548343510Medicare NSC