Provider Demographics
NPI:1790215218
Name:KENNEDY MEDICAL GROUP PRACTICE P.C. D/B/A KENNEDY HEALTH ALLIANCE
Entity type:Organization
Organization Name:KENNEDY MEDICAL GROUP PRACTICE P.C. D/B/A KENNEDY HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP/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 1:205 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:
Mailing Address - Fax:856-344-2315
Practice Address - Street 1:900 MEDICAL CENTER DR STE 205
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2358
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:2017-06-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0411248Medicaid