Provider Demographics
NPI:1043438740
Name:KAISER PERMANENTE MID-ATLANTIC
Entity type:Organization
Organization Name:KAISER PERMANENTE MID-ATLANTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:703-922-1034
Mailing Address - Street 1:6010 GOOD LION CT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-4623
Mailing Address - Country:US
Mailing Address - Phone:703-922-1034
Mailing Address - Fax:703-922-1628
Practice Address - Street 1:6501 LOISDALE CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-1826
Practice Address - Country:US
Practice Address - Phone:703-922-1034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000949302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization