Provider Demographics
NPI:1982069688
Name:KENNEDY MEDICAL GROUP PRACTICE, PC
Entity Type:Organization
Organization Name:KENNEDY MEDICAL GROUP PRACTICE, PC
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:DO
Authorized Official - Phone:856-783-1987
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 1:151 FRIES MILL RD STE 102
Practice Address - Street 2:
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-2056
Practice Address - Country:US
Practice Address - Phone:856-352-6660
Practice Address - Fax:856-269-4258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty