Provider Demographics
NPI:1043378656
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:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR,CREDENTIALING/PROVIDER ENR
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SWINTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-257-2797
Mailing Address - Street 1:4000 GARDEN CITY DRIVE
Mailing Address - Street 2:4TH FLOOR PPQA
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-2418
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:301-816-7170
Practice Address - Street 1:KAISER PERMANENTE-SOUTH BALTIMORE
Practice Address - Street 2:1701 TWIN SPRINGS ROAD
Practice Address - City:HALETHORPE
Practice Address - State:MD
Practice Address - Zip Code:21227-3553
Practice Address - Country:US
Practice Address - Phone:410-737-5000
Practice Address - Fax:443-263-7381
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KAISER FOUNDATION HEALTH PLAN OF THE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-05
Last Update Date:2024-12-23
Deactivation Date:2024-12-02
Deactivation Code:
Reactivation Date:2024-12-20
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No163WP0200XNursing Service ProvidersRegistered NursePediatricsGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK679OtherMEDICARE GROUP ID
MDK679Medicare PIN