Healthcare Provider Details

I. General information

NPI: 1073884847
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LAUREL OAK RD
VOORHEES NJ
08043-4453
US

IV. Provider business mailing address

333 LAUREL OAK RD
VOORHEES NJ
08043-4453
US

V. Phone/Fax

Practice location:
  • Phone: 856-783-0191
  • Fax: 856-783-0264
Mailing address:
  • Phone: 856-783-0191
  • Fax: 856-783-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25MA09025500
License Number StateNJ

VIII. Authorized Official

Name: KATHY SCHLEIDER
Title or Position: VP CLINICAL INTEGRATION
Credential:
Phone: 856-344-7360