Provider Demographics
NPI:1033438643
Name:KENNEDY HEALTH SYSTEM
Entity Type:Organization
Organization Name:KENNEDY HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP. DIRECTOR, BEHAVIORAL HEALTH
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:
Authorized Official - Last Name:MICOLI
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MHA
Authorized Official - Phone:856-488-6701
Mailing Address - Street 1:2201 CHAPEL AVE W
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-2048
Mailing Address - Country:US
Mailing Address - Phone:856-488-6500
Mailing Address - Fax:856-488-6415
Practice Address - Street 1:454 HURFFVILLE CROSSKEYS RD
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2339
Practice Address - Country:US
Practice Address - Phone:856-582-1419
Practice Address - Fax:856-582-7661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4140206Medicare PIN