Provider Demographics
NPI:1568520070
Name:KAISER FOUNDATION HEALTH PLAN MID ATLANTIC STATES
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN MID ATLANTIC STATES
Other - Org Name:PENDERBROOK MEDICAL CENTER LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHEIF 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:CPA MBA
Authorized Official - Phone:301-816-5760
Mailing Address - Street 1:2101 E JEFFERSON STREET 3 WEST
Mailing Address - Street 2:KAISER PERMANENTE DATA MANAGEMENT DEPARTMENT
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 1:12011 LEE JACKSON HIGHWAY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3310
Practice Address - Country:US
Practice Address - Phone:703-257-3050
Practice Address - Fax:703-257-3042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty