Provider Demographics
NPI:1689740367
Name:KAISER FOUNDATION HEALTH PLAN
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN
Other - Org Name:CHAPEL HILL MEDICAL OFFICES LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:REVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-265-8844
Mailing Address - Street 1:12301 SNOW ROAD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44130
Mailing Address - Country:US
Mailing Address - Phone:216-265-8844
Mailing Address - Fax:216-265-8890
Practice Address - Street 1:1260 INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44310
Practice Address - Country:US
Practice Address - Phone:216-265-8844
Practice Address - Fax:216-265-8890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0211372Medicaid
OH0211372Medicaid