Provider Demographics
NPI:1629187125
Name:KENNEDY SURGICAL CENTER
Entity Type:Organization
Organization Name:KENNEDY SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:LARIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-661-5144
Mailing Address - Street 1:PO BOX 48023
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101-4823
Mailing Address - Country:US
Mailing Address - Phone:856-661-5164
Mailing Address - Fax:856-661-5274
Practice Address - Street 1:540 EGG HARBOR RD
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2336
Practice Address - Country:US
Practice Address - Phone:856-218-4900
Practice Address - Fax:856-256-1276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ82444261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7251009Medicaid
NJ7251009Medicaid