Provider Demographics
NPI:1407157597
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:DELEGATED OFFICIAL
Authorized Official - Prefix:MS
Authorized Official - First Name:LARA
Authorized Official - Middle Name:E
Authorized Official - Last Name:CROZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-816-2424
Mailing Address - Street 1:6104 OLD BRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-2518
Mailing Address - Country:US
Mailing Address - Phone:301-702-6109
Mailing Address - Fax:
Practice Address - Street 1:6104 OLD BRANCH AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-2518
Practice Address - Country:US
Practice Address - Phone:301-702-6109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR094722261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service