Provider Demographics
NPI:1760036511
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:COLONIAL FORGE MEDICAL CENTER LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:T
Authorized Official - Last Name:BUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-816-5867
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 HOSPITAL CENTER BLVD STE 110
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-6202
Practice Address - Country:US
Practice Address - Phone:540-602-6500
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:2019-07-30
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory