Basic Information
| Provider Information | |||||||||
| NPI: | 1073830550 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAISER PERMANENTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 HOSPITAL PKWY | ||||||||
| Address2: | SUITE NUMBER 370 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951191106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089723366 | ||||||||
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| Practice Location | |||||||||
| Address1: | 275 HOSPITAL PKWY | ||||||||
| Address2: | SUITE NUMBER 370 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951191106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089723366 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2010 | ||||||||
| LastUpdateDate: | 04/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | PEDERSEN | ||||||||
| AuthorizedOfficialFirstName: | ERIK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRIMARY SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 4083634864 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSY.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.