Provider Demographics
NPI:1649296294
Name:KENNEDY UNIVERSITY HOSPITAL, INC
Entity type:Organization
Organization Name:KENNEDY UNIVERSITY HOSPITAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-557-5555
Mailing Address - Street 1:445 HURFFVILLE - CROSSKEYS RD
Mailing Address - Street 2:BUILDING A
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080
Mailing Address - Country:US
Mailing Address - Phone:856-557-5555
Mailing Address - Fax:856-218-2873
Practice Address - Street 1:445 HURFFVILLE CROSSKEYS RD BLDG A
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2337
Practice Address - Country:US
Practice Address - Phone:856-557-5555
Practice Address - Fax:856-218-2873
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNEDY MEMORIAL HOSPITAL UNIVERSITY MEDICAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-15
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ10802207Q00000X, 207V00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6843301Medicaid
NJ4140222Medicaid
NJ6843301Medicaid