Provider Demographics
NPI:1043580806
Name:KENNEDY MEDICAL GROUP PRACTICE, P.C.
Entity type:Organization
Organization Name:KENNEDY MEDICAL GROUP PRACTICE, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP CLINICAL INTEGRATION
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHLEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-783-1892
Mailing Address - Street 1:900 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2358
Mailing Address - Country:US
Mailing Address - Phone:856-218-2100
Mailing Address - Fax:
Practice Address - Street 1:900 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2358
Practice Address - Country:US
Practice Address - Phone:856-218-2100
Practice Address - Fax:856-218-2101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNEDY MEMORIAL HOSPITAL UNIVERSITY MEDICAL CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-10
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA086513002086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Single Specialty