Provider Demographics
NPI:1578606950
Name:KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Other - Org Name:KAISER PERMANENTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHRM COMPL MANG
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:404-949-5242
Mailing Address - Street 1:3640 TRAMORE POINTE PKWY
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6825
Mailing Address - Country:US
Mailing Address - Phone:770-439-4703
Mailing Address - Fax:770-439-4743
Practice Address - Street 1:3640 TRAMORE POINTE PKWY
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6825
Practice Address - Country:US
Practice Address - Phone:770-439-4703
Practice Address - Fax:770-439-4743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0091183336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2016476OtherPK