Basic Information
| Provider Information | |||||||||
| NPI: | 1639223050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANIKKANNAN | ||||||||
| FirstName: | SOWMYA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 E LAUREL RD | ||||||||
| Address2: | KENNEDY HOSPITAL | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666845 | ||||||||
| FaxNumber: | 8565666906 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 E LAUREL RD | ||||||||
| Address2: | KENNEDY HOSPITAL | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666845 | ||||||||
| FaxNumber: | 8565666906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD430524 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 25MA09242700 | NJ | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 25MA09242700 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1018195960002 | 05 | PA | MEDICAID | 2094417 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 1018195960003 | 05 | PA | MEDICAID | P01224369 | 01 | NJ | RAILROAD MEDICARE | OTHER | 2854908000 | 01 | PA | INDEPENDENCE BCBS | OTHER | 0342467 | 05 | NJ | MEDICAID | 1018195960001 | 05 | PA | MEDICAID |