Basic Information
| Provider Information | |||||||||
| NPI: | 1366533770 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY UNIVERSITY HOSPITAL INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENNEDY DIALYSIS CENTER - WASHINGTON TOWNSHIP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13703 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191013703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566615164 | ||||||||
| FaxNumber: | 8566615274 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 MEDICAL CENTER DRIVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562184990 | ||||||||
| FaxNumber: | 8562569624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 12/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | LARIO | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8566615144 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 1080 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 4140206 | 05 | NJ | MEDICAID |