1104984616 NPI number — KAISER FOUNDATION HEALTH PLAN MID ATLANTIC STATES

Table of content: (NPI 1104984616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104984616 NPI number — KAISER FOUNDATION HEALTH PLAN MID ATLANTIC STATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KAISER FOUNDATION HEALTH PLAN MID ATLANTIC STATES
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:
LOUDOUN MEDICAL CENTER LABORATORY
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:
1104984616
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 E JEFFERSON ST
Provider Second Line Business Mailing Address:
PPQA MEDICARE COMPLIANCE UNIT 6W
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20852-4908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-816-7446
Provider Business Mailing Address Fax Number:
301-816-7170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19450 DEERFIELD AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANDSDOWNE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20176-6821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-729-2626
Provider Business Practice Location Address Fax Number:
703-729-3141
Provider Enumeration Date:
12/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSEN
Authorized Official First Name:
ANDEE
Authorized Official Middle Name:
G
Authorized Official Title or Position:
CHEIF FINANCIAL OFFICER
Authorized Official Telephone Number:
301-816-5760

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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