Healthcare Provider Details

I. General information

NPI: 1609917103
Provider Name (Legal Business Name): KAISER FOUNDATION HEALTH PLAN OF GA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date: 01/28/2022
Reactivation Date: 03/09/2023

III. Provider practice location address

KP GLENHKE MEDICAL CENTER 20 GLENLAKE PKWY
ATLANTA GA
30328
US

IV. Provider business mailing address

3495 PIEDMONT ROAD NE NINE PIEDMONT CENTER
ATLANTA GA
30305
US

V. Phone/Fax

Practice location:
  • Phone: 770-677-6043
  • Fax:
Mailing address:
  • Phone: 404-364-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: F BOONE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 404-364-7293