Provider Demographics
NPI:1598937617
Name:KENNEDY MEDICAL GROUP PRACTICE P.C.
Entity Type:Organization
Organization Name:KENNEDY MEDICAL GROUP PRACTICE P.C.
Other - Org Name:KENNEDY HEALTH ALLIANCE POINT PLAZA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
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:856-344-7360
Mailing Address - Fax:856-783-1403
Practice Address - Street 1:565 EGG HARBOR RD
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2335
Practice Address - Country:US
Practice Address - Phone:856-256-0600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ747988Medicare PIN