Provider Demographics
NPI:1497295109
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:A
Authorized Official - Last Name:CIERVO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-344-7360
Mailing Address - Street 1:900 ROUTE 168
Mailing Address - Street 2:SUITE C#3
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-3233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 ROUTE 168
Practice Address - Street 2:SUITE C#3
Practice Address - City:BLACKWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08012-3233
Practice Address - Country:US
Practice Address - Phone:856-857-6920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0411248Medicaid
NJ348438Medicare PIN