Healthcare Provider Details

I. General information

NPI: 1902271992
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

668 MAIN ST STE. 4
LUMBERTON NJ
08048-5016
US

IV. Provider business mailing address

333 LAUREL OAK RD
VOORHEES NJ
08043-4453
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHERINE SCHLEIDER
Title or Position: VP
Credential:
Phone: 856-783-1987