Provider Demographics
NPI:1578678462
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 CRESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY COMPLIANCE MGR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS-HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-949-5336
Mailing Address - Street 1:200 CRESCENT CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-7047
Mailing Address - Country:US
Mailing Address - Phone:770-496-3523
Mailing Address - Fax:770-496-3713
Practice Address - Street 1:200 CRESCENT CENTER PKWY
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-7047
Practice Address - Country:US
Practice Address - Phone:770-496-3523
Practice Address - Fax:770-496-3713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0070073336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1136111OtherNCPDP PROVIDER IDENTIFICATION NUMBER