Healthcare Provider Details

I. General information

NPI: 1619365152
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: 01/07/2015
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E LAUREL RD
STRATFORD NJ
08084-1301
US

IV. Provider business mailing address

1A REGULUS DRIVE
TURNERSVILLE NJ
08012
US

V. Phone/Fax

Practice location:
  • Phone: 856-783-1987
  • Fax:
Mailing address:
  • Phone: 856-553-6904
  • Fax: 856-589-3913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number25MB03744500
License Number StateNJ

VIII. Authorized Official

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