Basic Information
Provider Information
NPI: 1598937617
EntityType: 2
ReplacementNPI:  
OrganizationName: KENNEDY MEDICAL GROUP PRACTICE P.C.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: KENNEDY HEALTH ALLIANCE POINT PLAZA
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 333 LAUREL OAK RD
Address2:  
City: VOORHEES
State: NJ
PostalCode: 080434453
CountryCode: US
TelephoneNumber: 8563447360
FaxNumber: 8567831403
Practice Location
Address1: 565 EGG HARBOR RD
Address2:  
City: SEWELL
State: NJ
PostalCode: 080802335
CountryCode: US
TelephoneNumber: 8562560600
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/28/2008
LastUpdateDate: 07/27/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: TAYLOR
AuthorizedOfficialFirstName: GREG
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: PHYSICIAN
AuthorizedOfficialTelephone: 8563447360
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: D.O.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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