Basic Information
| Provider Information | |||||||||
| NPI: | 1841232626 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KAISER PERMANENTE TOWNPARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 750 TOWNPARK LN NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301445579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705145500 | ||||||||
| FaxNumber: | 7705145514 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 TOWNPARK LN NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301445579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705145500 | ||||||||
| FaxNumber: | 7705145514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SANDERS | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHCY COMPLIANCE MGR | ||||||||
| AuthorizedOfficialTelephone: | 7707125654 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336M0003X | PHRE07745 | GA | Y | Suppliers | Pharmacy | Managed Care Organization Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1140982 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |