Healthcare Provider Details

I. General information

NPI: 1972606473
Provider Name (Legal Business Name): KAISER FOUNDATION HEALTH PLAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3288 MOANALUA RD RADIOLOGY DEPARTMENT
HONOLULU HI
96819-1469
US

IV. Provider business mailing address

711 KAPIOLANI BLVD BILLING DEPARTMENT
HONOLULU HI
96813-5214
US

V. Phone/Fax

Practice location:
  • Phone: 808-432-7341
  • Fax: 808-432-7340
Mailing address:
  • Phone: 808-432-5312
  • Fax: 808-432-5239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number150623
License Number StateHI

VIII. Authorized Official

Name: THOMAS J. RISSE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 808-432-5276