Provider Demographics
NPI:1881987337
Name:KENNEDY MEDICAL GROUP PRACTICE P.C.
Entity type:Organization
Organization Name:KENNEDY MEDICAL GROUP PRACTICE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARMAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CIERVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-783-1987
Mailing Address - Street 1:1 A REGULUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012
Mailing Address - Country:US
Mailing Address - Phone:856-256-7513
Mailing Address - Fax:856-256-7518
Practice Address - Street 1:1 A REGULUS DRIVE
Practice Address - Street 2:
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012
Practice Address - Country:US
Practice Address - Phone:856-256-7513
Practice Address - Fax:856-256-7518
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNEDY HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-17
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RE0101X, 2086S0129X
NJ25MB05175300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty