Healthcare Provider Details

I. General information

NPI: 1952615981
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 PRINCETON AVE WEST DEPTFORD
WEST DEPTFORD NJ
08096-3123
US

IV. Provider business mailing address

205 E. LAUREL ROAD
STRATFORD NJ
08084
US

V. Phone/Fax

Practice location:
  • Phone: 856-384-0210
  • Fax: 856-384-0218
Mailing address:
  • Phone: 856-783-1987
  • Fax: 856-783-1403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB08173000
License Number StateNJ

VIII. Authorized Official

Name: KATHERINE SCHLEIDER
Title or Position: VP CLINICAL INTEGRATION
Credential:
Phone: 856-783-1892