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General NPI Number Information
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NPI Number | 1871039180
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Entity Type | Organization
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Legal Business Name | KENNEDY MEDICAL GROUP PRACTICE P.C.
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Dates
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Enumeration Date | 01/10/2017
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Last Update Date | 01/10/2017
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Provider Practice Location Address
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Address Line | 100 BLACK HORSE PIKE
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City | AUDUBON
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State | NJ
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Zip | 08106-1950
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Country | US
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Telephone | 844-542-2273
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Fax |
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Provider Business Mailing Address
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Address Line | 205 E LAUREL RD
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City | STRATFORD
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State | NJ
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Zip | 08084-1301
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Country | US
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Telephone | 856-344-7360
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Fax | 856-344-2315
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Authorized Official
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Title or Position | CPE
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Name | CARMAN CIERVO
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Credential | D.O.
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Telephone | 856-344-7360
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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