Healthcare Provider Details

I. General information

NPI: 1235322165
Provider Name (Legal Business Name): KENNEDY U GANTI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 JOHN F KENNEDY WAY
WILLINGBORO NJ
08046-1262
US

IV. Provider business mailing address

1 FEDERAL ST # 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 609-835-2838
  • Fax: 609-589-3841
Mailing address:
  • Phone: 856-356-4924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License Number25MA08152400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA08152400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: