Provider Demographics
NPI:1376601872
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:KENSIGNTON MEDICAL CENTER PHYSICAL THERAPY
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 STREET
Mailing Address - Street 2:3 WEST ATTN SANJAY MATHUR
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-7446
Mailing Address - Fax:301-816-7170
Practice Address - Street 1:10410 NORTH KENSINGTON PARKWAY
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2138
Practice Address - Country:US
Practice Address - Phone:301-897-2330
Practice Address - Fax:301-929-7129
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 Licenses
StateLicense IDTaxonomies
2085R0202X, 302R00000X
2000X261Q225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG01288OtherMEDICARE GROUP ID
MDG01288Medicare PIN