Basic Information
| Provider Information | |||||||||
| NPI: | 1932511987 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY MEDICAL GROUP PRACTICE, P.C. | ||||||||
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| OtherOrganizationName: | KENNEDY HEALTH ALLIANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 E LAUREL RD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567831987 | ||||||||
| FaxNumber: | 8567831403 | ||||||||
| Practice Location | |||||||||
| Address1: | 188 FRIES MILL RD | ||||||||
| Address2: | SUITE N3 | ||||||||
| City: | BLACKWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080122015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568750505 | ||||||||
| FaxNumber: | 8568759556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2014 | ||||||||
| LastUpdateDate: | 07/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | SCHLEIDER | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VPCLINICAL INTEGRATION & POPULATION | ||||||||
| AuthorizedOfficialTelephone: | 8567831987 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 3911101 | 05 | NJ | MEDICAID | P00633440 | 01 | NJ | RAILROAD MEDICARE | OTHER |