Provider Demographics
NPI:1790120152
Name:KENNEDY MEDICAL GROUP D/B/A KENNEDY HEALTH ALLIANCE
Entity Type:Organization
Organization Name:KENNEDY MEDICAL GROUP D/B/A KENNEDY HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHLEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-783-1987
Mailing Address - Street 1:900 NEW JERSEY 168 NORTH
Mailing Address - Street 2:STE. C3
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012
Mailing Address - Country:US
Mailing Address - Phone:856-374-0430
Mailing Address - Fax:
Practice Address - Street 1:900 NEW JERSEY 168 NORTH
Practice Address - Street 2:STE. C3
Practice Address - City:BLACKWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08012
Practice Address - Country:US
Practice Address - Phone:856-374-0430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty