Basic Information
| Provider Information | |||||||||
| NPI: | 1083985857 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNEDY MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENNEDY HEALTH ALLIANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 73 N MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080531782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565960558 | ||||||||
| FaxNumber: | 8565964043 | ||||||||
| Practice Location | |||||||||
| Address1: | 73 N MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080531782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565960558 | ||||||||
| FaxNumber: | 8565964043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2012 | ||||||||
| LastUpdateDate: | 08/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | SCHLEIDER | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PHYSICIAN 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 | 2084N0400X | 25MB04815900 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.