Provider Demographics
NPI:1902217607
Name:KENNEDY MEDICAL GROUP PRACTICE, P.C. D/B/A KENNEDY HEALTH ALLIANCE
Entity Type:Organization
Organization Name:KENNEDY MEDICAL GROUP PRACTICE, P.C. D/B/A KENNEDY HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:856-262-8100
Mailing Address - Street 1:1300 LIBERTY PL
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-5710
Mailing Address - Country:US
Mailing Address - Phone:856-262-8100
Mailing Address - Fax:856-885-6859
Practice Address - Street 1:1300 LIBERTY PL
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-5710
Practice Address - Country:US
Practice Address - Phone:856-262-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-15
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00504300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty