Basic Information
| Provider Information | |||||||||
| NPI: | 1235517707 | ||||||||
| 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: | 100 BLACK HORSE PIKE | ||||||||
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| City: | AUDUBON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081061950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8445422273 | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 E LAUREL RD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567831987 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2015 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | SCHLEIDER | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP CLINICAL INTEGRATION | ||||||||
| AuthorizedOfficialTelephone: | 8567831987 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.