Healthcare Provider Details

I. General information

NPI: 1790215218
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE P.C. D/B/A KENNEDY HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MEDICAL CENTER DR STE 205
SEWELL NJ
08080-2358
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:
  • Fax: 856-344-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: CARMAN CIERVO
Title or Position: EVP/CPE
Credential:
Phone: 856-344-7360