Provider Demographics
NPI:1073884847
Name:KENNEDY MEDICAL GROUP PRACTICE, P.C.
Entity Type:Organization
Organization Name:KENNEDY MEDICAL GROUP PRACTICE, P.C.
Other - Org Name:KENNEDY HEALTH ALLIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CLINICAL INTEGRATION
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHLEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-344-7360
Mailing Address - Street 1:333 LAUREL OAK RD
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4453
Mailing Address - Country:US
Mailing Address - Phone:856-783-0191
Mailing Address - Fax:856-783-0264
Practice Address - Street 1:333 LAUREL OAK RD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4453
Practice Address - Country:US
Practice Address - Phone:856-783-0191
Practice Address - Fax:856-783-0264
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNEDY MEMORIAL HOSPITAL UNIVERSITY MEDICAL CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-25
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA090255002086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty