Healthcare Provider Details

I. General information

NPI: 1326065087
Provider Name (Legal Business Name): KENNEDY MEDICAL GROUP PRACTICE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 HADDONFIELD BERLIN RD
VOORHEES NJ
08043-3714
US

IV. Provider business mailing address

709 HADDONFIELD BERLIN RD
VOORHEES NJ
08043-3714
US

V. Phone/Fax

Practice location:
  • Phone: 856-566-3190
  • Fax: 856-566-1903
Mailing address:
  • Phone: 856-566-3190
  • Fax: 856-566-1903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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