Provider Demographics
NPI: | 1952461816 |
---|---|
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 ANNAPOLIS MEDICAL CENTER |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CHIEF FINANCIAL OFFICER |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | ANDEE |
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 STREET 3 WEST |
Mailing Address - Street 2: | DATA MANAGEMENT DEPT ATTN SANJAY MATHUR |
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: | 888 BESTGATE ROAD |
Practice Address - Street 2: | |
Practice Address - City: | ANNAPOLIS |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21401-3091 |
Practice Address - Country: | US |
Practice Address - Phone: | 410-571-7300 |
Practice Address - Fax: | 410-571-7309 |
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: | 2006-12-11 |
Last Update Date: | 2021-05-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 302R00000X | Managed Care Organizations | Health Maintenance Organization | Group - Multi-Specialty | |
No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
No | 133N00000X | Dietary & Nutritional Service Providers | Nutritionist | Group - Multi-Specialty | |
No | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Multi-Specialty | |
No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RS0012X | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
410092 | Medicare ID - Type Unspecified |