Healthcare Provider Details

I. General information

NPI: 1518025071
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:
Reactivation Date:

III. Provider practice location address

4920 CAMPBELL BOULEVARD
WHITE MARSH MD
21236-5916
US

IV. Provider business mailing address

4000 GARDEN CITY DR
HYATTSVILLE MD
20785-2418
US

V. Phone/Fax

Practice location:
  • Phone: 410-933-7626
  • Fax:
Mailing address:
  • Phone: 301-816-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: COLLEEN E SWINTON
Title or Position: CREDENTIALING DIRECTOR
Credential:
Phone: 301-257-2729