Basic Information
| Provider Information | |||||||||
| NPI: | 1225559495 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEDY MEDICAL GROUP PRACTICE P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENNEDY HEALTH ALLIANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 E LAUREL RD | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8563442315 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 CHAPEL AVENUE WEST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566652017 | ||||||||
| FaxNumber: | 8564886769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2017 | ||||||||
| LastUpdateDate: | 06/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | CIERVO | ||||||||
| AuthorizedOfficialFirstName: | CARMAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXP/CPE | ||||||||
| AuthorizedOfficialTelephone: | 8563447360 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0411248 | 05 | NJ | MEDICAID |