Basic Information
| Provider Information | |||||||||
| NPI: | 1811327638 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY MEDICAL GROUP D/B/A KENNEDY HEALTH ALLIANCE | ||||||||
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| OtherOrganizationName: | KENNEDY HEALTH ALLIANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1A REGULUS DRIVE | ||||||||
| Address2: | |||||||||
| City: | TURNERSVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562567513 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1A REGULUS DRIVE | ||||||||
| Address2: | |||||||||
| City: | TURNERSVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562567513 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2013 | ||||||||
| LastUpdateDate: | 11/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | SCHLEIDER | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT - CLINICAL INTEGRATI | ||||||||
| AuthorizedOfficialTelephone: | 8567831892 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 255220 | 05 | NJ | MEDICAID |