Provider Demographics
NPI:1669847646
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:
Authorized Official - Phone:856-344-7360
Mailing Address - Street 1:333 LAUREL OAK RD
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4453
Mailing Address - Country:US
Mailing Address - Phone:856-783-1987
Mailing Address - Fax:856-783-1403
Practice Address - Street 1:2211 CHAPEL AVE WEST
Practice Address - Street 2:STE 301
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002
Practice Address - Country:US
Practice Address - Phone:856-665-2017
Practice Address - Fax:856-488-6769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0411248Medicaid