Healthcare Provider Details

I. General information

NPI: 1164834297
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2014
Last Update Date: 05/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 EVESHAM ROAD SUITE 406
VOORHEES NJ
08043
US

IV. Provider business mailing address

205 E. LAUREL ROAD 2ND FLOOR
STRATFORD NJ
08084
US

V. Phone/Fax

Practice location:
  • Phone: 856-772-9600
  • Fax: 856-772-9650
Mailing address:
  • Phone: 856-783-1987
  • Fax: 856-783-1403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number25MB083854300
License Number StateNJ

VIII. Authorized Official

Name: KATHERINE SCHLEIDER
Title or Position: VPCLINICAL INTEGRATION & POPULATION
Credential:
Phone: 856-783-1987