Provider Demographics
NPI:1952615981
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:VP CLINICAL INTEGRATION
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:856-783-1892
Mailing Address - Street 1:205 E. LAUREL ROAD
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084
Mailing Address - Country:US
Mailing Address - Phone:856-783-1987
Mailing Address - Fax:856-783-1403
Practice Address - Street 1:165 PRINCETON AVE
Practice Address - Street 2:WEST DEPTFORD
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-3123
Practice Address - Country:US
Practice Address - Phone:856-384-0210
Practice Address - Fax:856-384-0218
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNEDY UNIVERSITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-02
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08173000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty