Provider Demographics
NPI:1376601872
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
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SWINTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-257-2797
Mailing Address - Street 1:4000 GARDEN CITY DR
Mailing Address - Street 2:
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:
Practice Address - Street 1:10410 NORTH KENSINGTON PARKWAY
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2138
Practice Address - Country:US
Practice Address - Phone:301-897-2330
Practice Address - Fax:301-929-7129
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES,INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-05
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2000X, 302R00000X
2000X261Q225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG01288OtherMEDICARE GROUP ID
MDG01288Medicare PIN