Healthcare Provider Details

I. General information

NPI: 1881987337
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 10/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 A REGULUS DRIVE
TURNERSVILLE NJ
08012
US

IV. Provider business mailing address

1 A REGULUS DRIVE
TURNERSVILLE NJ
08012
US

V. Phone/Fax

Practice location:
  • Phone: 856-256-7513
  • Fax: 856-256-7518
Mailing address:
  • Phone: 856-256-7513
  • Fax: 856-256-7518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB05175300
License Number StateNJ

VIII. Authorized Official

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