Basic Information
| Provider Information | |||||||||
| NPI: | 1699861914 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY MEMORIAL HOSPITALS-UNIVERSITY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 48023 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071014823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566615164 | ||||||||
| FaxNumber: | 8566615274 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 CHAPEL AVE W | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564886500 | ||||||||
| FaxNumber: | 8564886526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LARIO | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| 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 | 276400000X | 10401 | NJ | Y | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
ID Information
| ID | Type | State | Issuer | Description | 4140206 | 05 | NJ | MEDICAID |