Healthcare Provider Details

I. General information

NPI: 1043378656
Provider Name (Legal Business Name): KAISER FOUNDATION HEALTH PLAN OF THE MID ATLANTIC STATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date: 12/02/2024
Reactivation Date: 12/20/2024

III. Provider practice location address

KAISER PERMANENTE-SOUTH BALTIMORE 1701 TWIN SPRINGS ROAD
HALETHORPE MD
21227-3553
US

IV. Provider business mailing address

4000 GARDEN CITY DRIVE 4TH FLOOR PPQA
HYATTSVILLE MD
20785-2418
US

V. Phone/Fax

Practice location:
  • Phone: 410-737-5000
  • Fax: 443-263-7381
Mailing address:
  • Phone: 301-816-2424
  • Fax: 301-816-7170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 11
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: COLLEEN E SWINTON
Title or Position: DIRECTOR,CREDENTIALING/PROVIDER ENR
Credential:
Phone: 301-257-2797