=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073242517
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAISER FOUNDATION HEALTH PLAN OF THE MID ATLANTIC STATES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2022
-----------------------------------------------------
Last Update Date | 07/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5620 AGER ROAD
-----------------------------------------------------
City | HYATTSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-906-6600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4000 GARDEN CITY DR
-----------------------------------------------------
City | HYATTSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20785-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-816-2424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, CREDENTIALING
-----------------------------------------------------
Name | COLLEEN SWINTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-257-2797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336M0003X
-----------------------------------------------------
Taxonomy Name | Managed Care Organization Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------