Provider Demographics
NPI:1821118373
Name:KAISER FOUNDATION HEALTH OF THE PLAN MID-ATLANTIC STATES,INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH OF THE PLAN MID-ATLANTIC STATES,INC
Other - Org Name:KAISER PERMANENTE IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHEIF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANDEE
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA, MBA
Authorized Official - Phone:301-816-5760
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:301-816-7446
Mailing Address - Fax:301-816-7170
Practice Address - Street 1:8261 WILLOW OAKS CORPORATE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4512
Practice Address - Country:US
Practice Address - Phone:703-205-3600
Practice Address - Fax:703-205-3650
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KAISER FOUNDATION HEALTH OF THE PLAN MID-ATLANTIC STATES,INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-29
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
410092Medicare ID - Type UnspecifiedMEDICARE GROUP ID