MEDICARE: KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336M0003X	Managed Care Organization Pharmacy	PHRE009118	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2016476	OTHER		PK

General Provider Information

NPI Number	:	1578606950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.

Provider Business Mailing Address
First Line	:	3640 TRAMORE POINTE PKWY
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30106-6825
Country	:	US
Telephone Number	:	770-439-4703
Fax Number	:	770-439-4743

Provider Business Practice Location Address
First Line	:	3640 TRAMORE POINTE PKWY
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30106-6825
Country	:	US
Telephone Number	:	770-439-4703
Fax Number	:	770-439-4743

Authorized Official
Title or Position	:	PHRM COMPL MANG
Name	:	DIANE SANDERS
Credential	:	RPH
Telephone Number	:	404-949-5242

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	08/04/2021

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