Provider Demographics
NPI:1356013577
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:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:KURT
Authorized Official - Last Name:RICKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-741-2874
Mailing Address - Street 1:22370 DAVIS DR
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-5382
Mailing Address - Country:US
Mailing Address - Phone:703-919-7429
Mailing Address - Fax:
Practice Address - Street 1:2391 GREENSPRING DRIVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093
Practice Address - Country:US
Practice Address - Phone:410-847-3020
Practice Address - Fax:410-847-3022
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:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy