Basic Information
| Provider Information | |||||||||
| NPI: | 1043580806 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY MEDICAL GROUP PRACTICE, P.C. | ||||||||
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| OtherOrganizationName: | KENNEDY HEALTH ALLIANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562182100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562182100 | ||||||||
| FaxNumber: | 8562182101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2012 | ||||||||
| LastUpdateDate: | 06/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | SCHLEIDER | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP CLINICAL INTEGRATION | ||||||||
| AuthorizedOfficialTelephone: | 8567831892 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KENNEDY MEMORIAL HOSPITAL UNIVERSITY MEDICAL CENTER INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | 25MA08651300 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
No ID Information.