Provider Demographics
NPI:1639223050
Name:KANIKKANNAN, SOWMYA (MD)
Entity Type:Individual
Prefix:
First Name:SOWMYA
Middle Name:
Last Name:KANIKKANNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 E LAUREL RD
Mailing Address - Street 2:KENNEDY HOSPITAL
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1327
Mailing Address - Country:US
Mailing Address - Phone:856-566-6845
Mailing Address - Fax:856-566-6906
Practice Address - Street 1:18 E LAUREL RD
Practice Address - Street 2:KENNEDY HOSPITAL
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1327
Practice Address - Country:US
Practice Address - Phone:856-566-6845
Practice Address - Fax:856-566-6906
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430524207R00000X
NJ25MA09242700208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018195960002Medicaid
PA2094417OtherHIGHMARK BLUE SHIELD
PA1018195960003Medicaid
NJP01224369OtherRAILROAD MEDICARE
PA2854908000OtherINDEPENDENCE BCBS
NJ0342467Medicaid
PA1018195960001Medicaid
PAP00473979Medicare PIN
NJ274595AEDMedicare PIN
PA1018195960003Medicaid