Healthcare Provider Details

I. General information

NPI: 1790120152
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP D/B/A KENNEDY HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2013
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 NEW JERSEY 168 NORTH STE. C3
BLACKWOOD NJ
08012
US

IV. Provider business mailing address

900 NEW JERSEY 168 NORTH STE. C3
BLACKWOOD NJ
08012
US

V. Phone/Fax

Practice location:
  • Phone: 856-374-0430
  • Fax:
Mailing address:
  • Phone: 856-374-0430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MRS. KATHERINE SCHLEIDER
Title or Position: CORPORATE DIRECTOR
Credential:
Phone: 856-783-1987