Provider Demographics
NPI:1124186606
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:SEVERNA PARK MEDICAL CENTER PHARMACY
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 1:22370 DAVIS DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-5366
Mailing Address - Country:US
Mailing Address - Phone:703-466-4800
Mailing Address - Fax:703-466-4802
Practice Address - Street 1:8028 RICHIE HIGHWAY
Practice Address - Street 2:SUITE 134
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-1030
Practice Address - Country:US
Practice Address - Phone:410-553-2413
Practice Address - Fax:410-553-2427
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:2006-12-05
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy