Healthcare Provider Details

I. General information

NPI: 1437693421
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2016
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 KINGS HWY N N#4
CHERRY HILL NJ
08034-1919
US

IV. Provider business mailing address

205 E LAUREL RD
STRATFORD NJ
08084-1301
US

V. Phone/Fax

Practice location:
  • Phone: 844-542-2273
  • Fax:
Mailing address:
  • Phone: 856-344-7360
  • Fax: 856-344-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

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