Provider Demographics
NPI:1437410990
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:VICE PRESIDENT OF CLINICAL OPERATIO
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-218-5634
Mailing Address - Street 1:400 LAUREL OAK RD STE 105
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4455
Mailing Address - Country:US
Mailing Address - Phone:856-922-9894
Mailing Address - Fax:856-922-9890
Practice Address - Street 1:205 E LAUREL RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1301
Practice Address - Country:US
Practice Address - Phone:856-816-0255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty