Provider Demographics
NPI:1578885463
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:CREDENTIALING DIRECTOR
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 1:1221 MERCANTILE LN
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5374
Practice Address - Country:US
Practice Address - Phone:301-618-5880
Practice Address - Fax:301-618-5912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-19
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
MDPW03353336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123905OtherPK