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	333600000X	Pharmacy
2	3336M0002X	Mail Order Pharmacy
3	3336M0003X	Managed Care Organization Pharmacy	PHRE008623	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2014604	OTHER		PK

General Provider Information

NPI Number	:	1740395631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.

Provider Business Mailing Address
First Line	:	4000 DEKALB TEC PKWY
Second Line	:	STE 320
City	:	ATLANTA
State	:	GA
Zip	:	30340-2761
Country	:	US
Telephone Number	:	770-220-3787
Fax Number	:	770-220-3796

Provider Business Practice Location Address
First Line	:	4000 DEKALB TEC PKWY
Second Line	:	STE 320
City	:	ATLANTA
State	:	GA
Zip	:	30340-2761
Country	:	US
Telephone Number	:	770-220-3787
Fax Number	:	770-220-3796

Authorized Official
Title or Position	:	PHCY COMPLIANCE MGR
Name	:	MS. DIANE SANDERS
Credential	:
Telephone Number	:	770-712-5654

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	08/04/2021

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