1083606164 NPI number — KENNEDY UNIVERSITY HOSPITAL, INC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083606164 NPI number — KENNEDY UNIVERSITY HOSPITAL, INC

Employer Identification Number (EIN):

Provider Organization Name:

KENNEDY UNIVERSITY HOSPITAL, INC

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

Provider Other Organization Name Type Code:

6

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:

1083606164

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

05/08/2019

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

333 LAUREL OAK ROAD

Provider Second Line Business Mailing Address:

UNIT D

Provider Business Mailing Address City Name:

VOORHEES

Provider Business Mailing Address State Name:

NJ

Provider Business Mailing Address Postal Code:

08043

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

856-809-4300

Provider Business Mailing Address Fax Number:

856-566-9455

Provider First Line Business Practice Location Address:

1099 WHITE HORSE 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:

08043-4405

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

856-566-2000

Provider Business Practice Location Address Fax Number:

856-566-5288

Provider Enumeration Date:

08/16/2005

Authorized Official Last Name:

FLANNERY

Authorized Official First Name:

KATHLEEN

Authorized Official Middle Name:

D.

Authorized Official Title or Position:

ADMINISTRATOR

Authorized Official Telephone Number:

856-809-4331

• Taxonomy code: 251E00000X , with the licence number:  22365 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 4146506 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
• Identifier: 4146514 . This is a "CCPED MEDICAID" identifier . This identifiers is of the category "OTHER".
• Identifier: 317073 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 317073 . This is a "HORIZON HMO" identifier . This identifiers is of the category "OTHER".
• Identifier: 317073 . This is a "HORIZON PPO BLUE SELECT" identifier . This identifiers is of the category "OTHER".
• Identifier: 317073 . This is a "HORIZON PPO BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
• Identifier: 2K1918 . This is a "HEALTHNET" identifier . This identifiers is of the category "OTHER".
• Identifier: 317073 . This is a "MEDICARE PART B" identifier . This identifiers is of the category "OTHER".
• Identifier: 317073 . This is a "HORIZON MEDICARE POS" identifier . This identifiers is of the category "OTHER".
• Identifier: 317073 . This is a "HORIZON NJ PLUS" identifier . This identifiers is of the category "OTHER".
• Identifier: 317073 . This is a "HORIZON HMO BLUE" identifier . This identifiers is of the category "OTHER".
• Identifier: 317073 . This is a "COMPSOURCE" identifier . This identifiers is of the category "OTHER".
• Identifier: 317073 . This is a "HORIZON POS" identifier . This identifiers is of the category "OTHER".
• Identifier: 317073 . This is a "HORIZON BLUE CARD PPO" identifier . This identifiers is of the category "OTHER".