Healthcare Provider Details

I. General information

NPI: 1881138154
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 B SOUTH WHITE HORSE PIKE
HAMMONTON NJ
08037
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 Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

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