1831411628 NPI number — KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC

Table of content: (NPI 1831411628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831411628 NPI number — KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KAISER PERMANENTE WOODLAWN INFUSION PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831411628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22370 DAVIS DR
Provider Second Line Business Mailing Address:
SUITE 190
Provider Business Mailing Address City Name:
STERLING
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20164-5367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-466-4800
Provider Business Mailing Address Fax Number:
703-466-4802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7141 SECURITY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21244-1811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-663-6435
Provider Business Practice Location Address Fax Number:
443-663-6430
Provider Enumeration Date:
02/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CONNERY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY BENEFITS COORDINATOR
Authorized Official Telephone Number:
703-466-4800

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: PW0333 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2135146 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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