Healthcare Provider Details

I. General information

NPI: 1093051468
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MEDICAL CENTER DR STE 100
SEWELL NJ
08080-2358
US

IV. Provider business mailing address

457 HADDONFIELD RD STE 110 LIBERTY VIEW CHERRY HILL
CHERRY HILL NJ
08002-2223
US

V. Phone/Fax

Practice location:
  • Phone: 856-582-3008
  • Fax: 856-582-3009
Mailing address:
  • Phone: 856-406-4091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: CARMAN A CIERVO
Title or Position: CPE
Credential:
Phone: 856-783-1987