Provider Demographics
NPI:1205114071
Name:KENNEDY MEDICAL GROUP PRACTICE, P.C.
Entity type:Organization
Organization Name:KENNEDY MEDICAL GROUP PRACTICE, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP CLINICAL INTEGRATION
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHLEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-783-1892
Mailing Address - Street 1:205 E LAUREL RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1301
Mailing Address - Country:US
Mailing Address - Phone:856-783-0870
Mailing Address - Fax:856-783-1403
Practice Address - Street 1:205 E LAUREL RD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1301
Practice Address - Country:US
Practice Address - Phone:856-783-0870
Practice Address - Fax:856-783-0649
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNEDY MEMORIAL HOSPITAL UNIVERSITY MEDICAL CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-28
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05920500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty