Healthcare Provider Details

I. General information

NPI: 1497295109
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 ROUTE 168 SUITE C#3
BLACKWOOD NJ
08012-3233
US

IV. Provider business mailing address

900 ROUTE 168 SUITE C#3
BLACKWOOD NJ
08012-3233
US

V. Phone/Fax

Practice location:
  • Phone: 856-857-6920
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CARMAN A CIERVO
Title or Position: CPE
Credential: D.O.
Phone: 856-344-7360