Basic Information
| Provider Information | |||||||||
| NPI: | 1578975520 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY MEDICAL GROUP PRACTICE, P.C. | ||||||||
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| OtherOrganizationName: | D/B/A/ KENNEDY HEALTH ALLIANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 E. LAUREL ROAD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | STATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567831987 | ||||||||
| FaxNumber: | 8567831403 | ||||||||
| Practice Location | |||||||||
| Address1: | 485 WILLIAMSTOWN ROAD | ||||||||
| Address2: | |||||||||
| City: | SICKLERVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567729600 | ||||||||
| FaxNumber: | 8567729650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2014 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | SCHLEIDER | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VPCLINICAL INTEGRATION & POPULATION | ||||||||
| AuthorizedOfficialTelephone: | 8567831987 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KENNEDY MEDICAL GROUP PRACTICE, P.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 25MB03854300 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 3911101 | 05 | NJ | MEDICAID | P00633440 | 01 | NJ | RAILROAD MEDICARE | OTHER |