Healthcare Provider Details

I. General information

NPI: 1235517707
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE, P.C. D/B/A KENNEDY HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2015
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

100 BLACK HORSE PIKE
AUDUBON NJ
08106-1950
US

V. Phone/Fax

Practice location:
  • Phone: 856-783-1987
  • Fax:
Mailing address:
  • Phone: 844-542-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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