Provider Demographics
NPI:1174663470
Name:KENNEDY MEDICAL GROUP PRACTICE, P.C. D/B/A KENNEDY HEALTH ALLIANCE
Entity Type:Organization
Organization Name:KENNEDY MEDICAL GROUP PRACTICE, P.C. D/B/A KENNEDY HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CLINICAL INTEGRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
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:856-783-2244
Mailing Address - Fax:856-783-8537
Practice Address - Street 1:25 E LAUREL RD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1322
Practice Address - Country:US
Practice Address - Phone:856-783-2244
Practice Address - Fax:856-783-8537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0546509000OtherAMERIHEALTH
NJ0482818000OtherKEYSTONE
NJP1130008OtherOXFORD
NJ$$$$$$$$$OtherSOCIAL
NJ5616786OtherAETNA
NJ2320509Medicaid
NJ0083883000OtherAMERIHEALTH
NJ00074869OtherPERSONAL CHOICE
NJ4090653OtherAETNA
NJ146434Medicare ID - Type Unspecified
NJ00074869OtherPERSONAL CHOICE
NJ5616786OtherAETNA
NJ025194Medicare ID - Type Unspecified