Provider Demographics
NPI:1326065087
Name:KENNEDY MEDICAL GROUP PRACTICE P.C.
Entity Type:Organization
Organization Name:KENNEDY MEDICAL GROUP PRACTICE P.C.
Other - Org Name:KENNEDY HEALTH ALLIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CPE
Authorized Official - Prefix:
Authorized Official - First Name:CARMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CIERVO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-344-7360
Mailing Address - Street 1:709 HADDONFIELD BERLIN RD
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-3714
Mailing Address - Country:US
Mailing Address - Phone:856-566-3190
Mailing Address - Fax:856-566-1903
Practice Address - Street 1:709 HADDONFIELD BERLIN RD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-3714
Practice Address - Country:US
Practice Address - Phone:856-566-3190
Practice Address - Fax:856-566-1903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0411248Medicaid
NJ6270204Medicaid
NJCA2405OtherRAILROAD MEDICARE
NJ348438Medicare PIN
NJ6270204Medicaid