1164834297 NPI number — KENNEDY MEDICAL GROUP PRACTICE, P.C.

Table of content: (NPI 1164834297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164834297 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:
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 Information

NPI Number:
1164834297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 E. LAUREL ROAD
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
STRATFORD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-783-1987
Provider Business Mailing Address Fax Number:
856-783-1403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 EVESHAM ROAD
Provider Second Line Business Practice Location Address:
SUITE 406
Provider Business Practice Location Address City Name:
VOORHEES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-772-9600
Provider Business Practice Location Address Fax Number:
856-772-9650
Provider Enumeration Date:
05/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SCHLEIDER
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
Authorized Official Title or Position:
VPCLINICAL INTEGRATION & POPULATION
Authorized Official Telephone Number:
856-783-1987

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  25MB083854300 , 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)

  • Identifier: P00633440 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3911101 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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