Basic Information
| Provider Information | |||||||||
| NPI: | 1174663470 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY MEDICAL GROUP PRACTICE, P.C. D/B/A KENNEDY HEALTH ALLIANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 LAUREL OAK RD | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080434453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567832244 | ||||||||
| FaxNumber: | 8567838537 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 E LAUREL RD | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567832244 | ||||||||
| FaxNumber: | 8567838537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 05/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCHLEIDER | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP CLINICAL INTEGRATION | ||||||||
| AuthorizedOfficialTelephone: | 8563447360 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 0546509000 | 01 | NJ | AMERIHEALTH | OTHER | 0482818000 | 01 | NJ | KEYSTONE | OTHER | P1130008 | 01 | NJ | OXFORD | OTHER | $$$$$$$$$ | 01 | NJ | SOCIAL | OTHER | 5616786 | 01 | NJ | AETNA | OTHER | 2320509 | 05 | NJ | MEDICAID | 0083883000 | 01 | NJ | AMERIHEALTH | OTHER | 00074869 | 01 | NJ | PERSONAL CHOICE | OTHER | 4090653 | 01 | NJ | AETNA | OTHER |