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	PHRE009386	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1156240	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1922295310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.

Provider Business Mailing Address
First Line	:	1435 BROADMOOR BLVD
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30518-5408
Country	:	US
Telephone Number	:	678-765-5680
Fax Number	:	678-765-5682

Provider Business Practice Location Address
First Line	:	1435 BROADMOOR BLVD
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30518-5408
Country	:	US
Telephone Number	:	678-765-5680
Fax Number	:	678-765-5682

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

Provider Enumeration Date	:	09/28/2007
Last Update Date	:	08/04/2021

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