Healthcare Provider Details

I. General information

NPI: 1932511987
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 FRIES MILL RD SUITE N3
BLACKWOOD NJ
08012-2015
US

IV. Provider business mailing address

205 E LAUREL RD 2ND FLOOR
STRATFORD NJ
08084-1301
US

V. Phone/Fax

Practice location:
  • Phone: 856-875-0505
  • Fax: 856-875-9556
Mailing address:
  • Phone: 856-783-1987
  • Fax: 856-783-1403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number StateNJ

VIII. Authorized Official

Name: KATHERINE SCHLEIDER
Title or Position: VPCLINICAL INTEGRATION & POPULATION
Credential:
Phone: 856-783-1987