Provider Demographics
NPI:1942546486
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:SO. BALTIMORE COUNTY ASC
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:301-816-5760
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:3 WEST
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 1:1701 TWIN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:HALETHORPE
Practice Address - State:MD
Practice Address - Zip Code:21227-3553
Practice Address - Country:US
Practice Address - Phone:301-816-2424
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:2013-01-02
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical