Provider Demographics
NPI:1568996098
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:AVP
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-783-1267
Mailing Address - Street 1:151 FRIES MILL RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2016
Mailing Address - Country:US
Mailing Address - Phone:856-875-1209
Mailing Address - Fax:856-875-9556
Practice Address - Street 1:151 FRIES MILL RD
Practice Address - Street 2:SUITE 301
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-2016
Practice Address - Country:US
Practice Address - Phone:856-875-1209
Practice Address - Fax:856-875-9556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0411248Medicaid
NJ348438Medicare PIN