Provider Demographics
NPI:1932511987
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:VPCLINICAL INTEGRATION & POPULATION
Authorized Official - Prefix:
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 1:205 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:856-783-1987
Mailing Address - Fax:856-783-1403
Practice Address - Street 1:188 FRIES MILL RD
Practice Address - Street 2:SUITE N3
Practice Address - City:BLACKWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08012-2015
Practice Address - Country:US
Practice Address - Phone:856-875-0505
Practice Address - Fax:856-875-9556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-27
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3911101Medicaid
NJP00633440OtherRAILROAD MEDICARE
NJ631322Medicare PIN
NJP00633440OtherRAILROAD MEDICARE