Basic Information
| Provider Information | |||||||||
| NPI: | 1881987337 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNEDY MEDICAL GROUP PRACTICE P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1 A REGULUS DRIVE | ||||||||
| Address2: | |||||||||
| City: | TURNERSVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562567513 | ||||||||
| FaxNumber: | 8562567518 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 A REGULUS DRIVE | ||||||||
| Address2: | |||||||||
| City: | TURNERSVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562567513 | ||||||||
| FaxNumber: | 8562567518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2011 | ||||||||
| LastUpdateDate: | 10/19/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CIERVO | ||||||||
| AuthorizedOfficialFirstName: | CARMAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8567831987 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KENNEDY HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 207Q00000X | 25MB05175300 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.