Provider Demographics
NPI:1982766549
Name:KAISER PERMANENTE
Entity Type:Organization
Organization Name:KAISER PERMANENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:650-742-1350
Mailing Address - Street 1:1019 MONTEREY AVE
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-3717
Mailing Address - Country:US
Mailing Address - Phone:650-349-5676
Mailing Address - Fax:650-349-0382
Practice Address - Street 1:1200 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-3208
Practice Address - Country:US
Practice Address - Phone:650-742-1350
Practice Address - Fax:650-742-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA193145261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP95933ZZZ26680ZMedicare UPIN