Provider Demographics
NPI:1437693421
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 1:205 E LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1301
Mailing Address - Country:US
Mailing Address - Phone:856-344-7360
Mailing Address - Fax:856-344-2315
Practice Address - Street 1:1305 KINGS HWY N
Practice Address - Street 2:N#4
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1919
Practice Address - Country:US
Practice Address - Phone:844-542-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0411248Medicaid
NJ348438Medicare PIN