Healthcare Provider Details

I. General information

NPI: 1225559495
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 06/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 CHAPEL AVENUE WEST SUITE 301
CHERRY HILL NJ
08002
US

IV. Provider business mailing address

205 E LAUREL RD
STRATFORD NJ
08084-1301
US

V. Phone/Fax

Practice location:
  • Phone: 856-665-2017
  • Fax: 856-488-6769
Mailing address:
  • Phone:
  • Fax: 856-344-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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