MEDICARE: KAISER PERMANENTE INTERNAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336M0003X	Managed Care Organization Pharmacy	07798	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1141023	OTHER		OTHER ID NUMBER
2	1141023	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1205872686
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAISER PERMANENTE INTERNAL

Provider Business Mailing Address
First Line	:	200 CRES CTR PKWY
Second Line	:
City	:	TUCKER
State	:	GA
Zip	:	30084-7047
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 CRES CTR PKWY
Second Line	:
City	:	TUCKER
State	:	GA
Zip	:	30084-7047
Country	:	US
Telephone Number	:	770-496-3623
Fax Number	:	770-496-3528

Authorized Official
Title or Position	:	PHCY COMPLIANCE MGR GA
Name	:	DIANE SANDERS HARVEY
Credential	:
Telephone Number	:	404-949-5336

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	07/19/2007

Similar Medicare Providers

1750266219 — KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC
Practice Location Address:

200 CRESCENT CENTER PKWY
TUCKER, GA
30084-7047

Practice Phone: 770-621-6834
Practice Fax:

1972562791 — DR. EUGIA LITTLEJOHN MEMINGER PH.D
Practice Location Address:

200 CRESCENT CENTER PKWY
TUCKER, GA
30084-7047

Practice Phone: 404-365-0966
Practice Fax:

1649236407 — DR. DAWN MAURINE CARDWELL M.D.
Practice Location Address:

200 CRESCENT CENTER PKWY
TUCKER, GA
30084-7047

Practice Phone: 404-365-0966
Practice Fax:

1720016405 — DR. JENNIFER GALL KAPELLA MD
Practice Location Address:

200 CRESCENT CENTER PKWY , KAISER PERMANENTE CRESCENT MEDICAL CENTER
TUCKER, GA
30084-7047

Practice Phone: 404-364-7000
Practice Fax:

1245247006 — DR. DEREK KEITH RICHARDSON M.D.
Practice Location Address:

200 CRESCENT CENTER PKWY , KAISER PERMANENTE CRESCENT CENTRE MEDICAL CENTER
TUCKER, GA
30084-7047

Practice Phone: 770-496-3609
Practice Fax:

1578678462 — KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Practice Location Address:

200 CRESCENT CENTER PKWY
TUCKER, GA
30084-7047

Practice Phone: 770-496-3523
Practice Fax: 770-496-3713

Directions to “KAISER PERMANENTE INTERNAL ” Practice Location

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