Healthcare Provider Details

I. General information

NPI: 1043438740
Provider Name (Legal Business Name): KAISER PERMANENTE MID-ATLANTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 LOISDALE CT
SPRINGFIELD VA
22150-1826
US

IV. Provider business mailing address

6010 GOOD LION CT
ALEXANDRIA VA
22315-4623
US

V. Phone/Fax

Practice location:
  • Phone: 703-922-1034
  • Fax:
Mailing address:
  • Phone: 703-922-1034
  • Fax: 703-922-1628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number0103000949
License Number StateVA

VIII. Authorized Official

Name: DR. ELEANOR ANNE WILSON
Title or Position: PODIATRIST
Credential: DPM
Phone: 703-922-1034