Provider Demographics
NPI:1396781779
Name:KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Entity type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHCY COMPLIANCE MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-712-5654
Mailing Address - Street 1:3650 STEVE REYNOLDS BLVD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4506
Mailing Address - Country:US
Mailing Address - Phone:770-931-6134
Mailing Address - Fax:770-931-6403
Practice Address - Street 1:3650 STEVE REYNOLDS BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4506
Practice Address - Country:US
Practice Address - Phone:770-931-6134
Practice Address - Fax:770-931-6403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE077763336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1140956OtherNCPDP PROVIDER IDENTIFICATION NUMBER