Provider Demographics
NPI:1629343421
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:VP CLINICAL INTEGRATION
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KATHERINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-783-1982
Mailing Address - Street 1:205 E LAUREL RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1301
Mailing Address - Country:US
Mailing Address - Phone:856-783-1892
Mailing Address - Fax:856-783-1403
Practice Address - Street 1:543 EGG HARBOR ROAD
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:856-256-2063
Practice Address - Fax:856-256-2064
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNEDY MEMORIAL HOSPITAL UNIVERSITY MEDICAL CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-13
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA090255002086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty