MEDICARE: KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC.

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	291U00000X	Clinical Medical Laboratory	11D1074981	GA
2	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1972765717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC.

Provider Business Mailing Address
First Line	:	3495 PIEDMONT RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-1773
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1435 BROADMOOR BLVD
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30518-5408
Country	:	US
Telephone Number	:	678-765-5740
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF LABORATORY SERVICES
Name	:	KATHERINE FARMER
Credential	:
Telephone Number	:	404-309-9314

Provider Enumeration Date	:	07/01/2008
Last Update Date	:	07/15/2021

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