Provider Demographics
NPI:1164834297
Name:KENNEDY MEDICAL GROUP PRACTICE, P.C.
Entity Type:Organization
Organization Name:KENNEDY MEDICAL GROUP PRACTICE, P.C.
Other - Org Name:D/B/A/ KENNEDY HEALTH ALLIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VPCLINICAL INTEGRATION & POPULATION
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHLEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-783-1987
Mailing Address - Street 1:205 E. LAUREL ROAD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084
Mailing Address - Country:US
Mailing Address - Phone:856-783-1987
Mailing Address - Fax:856-783-1403
Practice Address - Street 1:2301 EVESHAM ROAD
Practice Address - Street 2:SUITE 406
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043
Practice Address - Country:US
Practice Address - Phone:856-772-9600
Practice Address - Fax:856-772-9650
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNEDY MEDICAL GROUP PRACTICE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-23
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB083854300208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00633440OtherRAILROAD MEDICARE
NJ3911101Medicaid
NJP00633440OtherRAILROAD MEDICARE
NJC54051Medicare UPIN