Basic Information
| Provider Information | |||||||||
| NPI: | 1073884847 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY MEDICAL GROUP PRACTICE, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENNEDY HEALTH ALLIANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 LAUREL OAK RD | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080434453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567830191 | ||||||||
| FaxNumber: | 8567830264 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 LAUREL OAK RD | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080434453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567830191 | ||||||||
| FaxNumber: | 8567830264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2012 | ||||||||
| LastUpdateDate: | 10/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | SCHLEIDER | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP CLINICAL INTEGRATION | ||||||||
| AuthorizedOfficialTelephone: | 8563447360 | ||||||||
| 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 | 2086S0129X | 25MA09025500 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.