Healthcare Provider Details

I. General information

NPI: 1982069688
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 FRIES MILL RD STE 102
TURNERSVILLE NJ
08012-2056
US

IV. Provider business mailing address

333 LAUREL OAK RD
VOORHEES NJ
08043-4453
US

V. Phone/Fax

Practice location:
  • Phone: 856-352-6660
  • Fax: 856-269-4258
Mailing address:
  • Phone: 856-783-1987
  • Fax: 856-783-1403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

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