1922295310 NPI number — KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922295310 NPI number — KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KAISER FOUNDATION HEALTH PLAN OF GEORGIA, 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:
Provider Other Organization Name Type Code:
6
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:
1922295310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1435 BROADMOOR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFORD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30518-5408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-765-5680
Provider Business Mailing Address Fax Number:
678-765-5682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1435 BROADMOOR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFORD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30518-5408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-765-5680
Provider Business Practice Location Address Fax Number:
678-765-5682
Provider Enumeration Date:
09/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SANDERS
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY COMPLIANCE MANAGER
Authorized Official Telephone Number:
770-712-5654

Provider Taxonomy Codes

  • Taxonomy code: 3336M0003X , with the licence number:  PHRE009386 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1156240 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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