Basic Information
| Provider Information | |||||||||
| NPI: | 1093051468 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY MEDICAL GROUP PRACTICE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 457 HADDONFIELD RD STE 110 | ||||||||
| Address2: | LIBERTY VIEW CHERRY HILL | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564064091 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 MEDICAL CENTER DR STE 100 | ||||||||
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| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565823008 | ||||||||
| FaxNumber: | 8565823009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2012 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | CIERVO | ||||||||
| AuthorizedOfficialFirstName: | CARMAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CPE | ||||||||
| AuthorizedOfficialTelephone: | 8567831987 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.