Healthcare Provider Details

I. General information

NPI: 1598203267
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 FRIES MILL RD SUITE 100
TURNERSVILLE NJ
08012-2016
US

IV. Provider business mailing address

151 FRIES MILL RD SUITE 100
TURNERSVILLE NJ
08012-2016
US

V. Phone/Fax

Practice location:
  • Phone: 856-566-3190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

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