Provider Demographics
NPI:1629223250
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:KAISER PERMANENTE FREDERICKSBURG PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNE
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-816-5780
Mailing Address - Street 1:22370 DAVIS DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-5366
Mailing Address - Country:US
Mailing Address - Phone:703-466-4800
Mailing Address - Fax:703-466-4802
Practice Address - Street 1:1201 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-8428
Practice Address - Country:US
Practice Address - Phone:540-368-3800
Practice Address - Fax:
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:2008-11-24
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010042613336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4841222OtherNCPDP PROVIDER IDENTIFICATION NUMBER