Provider Demographics
NPI:1164597019
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 BURKE ADMIXTURE 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 1:5999 BURKE COMMONS RD
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-2880
Practice Address - Country:US
Practice Address - Phone:703-249-7750
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:2006-11-22
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy