1811267693 NPI number — KENNEDY MEDICAL GROUP PRACTICE, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811267693 NPI number — KENNEDY MEDICAL GROUP PRACTICE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNEDY MEDICAL GROUP PRACTICE, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KENNEDY HEALTH ALLIANCE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811267693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 LAUREL OAK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VOORHEES
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08043-4453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-542-2273
Provider Business Mailing Address Fax Number:
856-770-9194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 LAUREL OAK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VOORHEES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043-4453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-542-2273
Provider Business Practice Location Address Fax Number:
856-770-9194
Provider Enumeration Date:
01/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SCHLEIDER
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP CLINICAL INTEGRATION
Authorized Official Telephone Number:
856-344-7360

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  25 MB08832100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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