Healthcare Provider Details

I. General information

NPI: 1295751832
Provider Name (Legal Business Name): KENNEDY UNIVERSITY HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SOMERDALE SQ
SOMERDALE NJ
08083-1345
US

IV. Provider business mailing address

1 SOMERDALE SQ
SOMERDALE NJ
08083-1345
US

V. Phone/Fax

Practice location:
  • Phone: 856-557-5555
  • Fax: 856-566-8944
Mailing address:
  • Phone: 856-557-5555
  • Fax: 856-566-8942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10403
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number10403
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number10403
License Number StateNJ

VIII. Authorized Official

Name: MRS. MICHELLE SILLS
Title or Position: OFFICE MANAGER
Credential:
Phone: 856-557-5555