Basic Information
| Provider Information | |||||||||
| NPI: | 1932564622 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY MEDICAL GROUP PRACTICE, PC | ||||||||
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| OtherOrganizationName: | KENNEDY HEALTH ALLIANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 LAUREL OAK RD | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080434453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567831987 | ||||||||
| FaxNumber: | 8567831403 | ||||||||
| Practice Location | |||||||||
| Address1: | 165 PRINCETON AVE | ||||||||
| Address2: | |||||||||
| City: | WEST DEPTFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080963123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567831987 | ||||||||
| FaxNumber: | 8567831403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2015 | ||||||||
| LastUpdateDate: | 01/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | SCHLEIDER | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP CLINICAL INTEGRATION&POP.HEALTH | ||||||||
| AuthorizedOfficialTelephone: | 8567831987 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.