Basic Information
| Provider Information | |||||||||
| NPI: | 1144544297 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY UNIVERSITY HOSPITAL, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENNEDY COMPREHENSIVE BREAST CENTER | ||||||||
| 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 | ||||||||
| FaxNumber: | 8562182101 | ||||||||
| 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: | 03/18/2010 | ||||||||
| LastUpdateDate: | 03/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | SCHLEIDER | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8562185710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 6843301 | 05 | NJ | MEDICAID |