Healthcare Provider Details

I. General information

NPI: 1811031743
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: 02/16/2007
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43480 YUKON DR STE 100
ASHBURN VA
20147-6988
US

IV. Provider business mailing address

4000 GARDEN CITY DR
HYATTSVILLE MD
20785-2418
US

V. Phone/Fax

Practice location:
  • Phone: 703-227-5006
  • 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 Number0201004121
License Number StateVA

VIII. Authorized Official

Name: COLLEEN SWINTON
Title or Position: CREDENTIALING DIRECTOR
Credential:
Phone: 301-257-2797