MEDICARE: INNERVISIONSONOGRAPHY INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2471V0105X	Vascular Sonography Radiologic Technologist		NY
2	2471S1302X	Sonography Radiologic Technologist		NY
3	246XS1301X	Sonography Specialist/Technologist Cardiovascular	00072877	NY

General Provider Information

NPI Number	:	1376842633
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNERVISIONSONOGRAPHY INC.

Provider Business Mailing Address
First Line	:	4064 BRUNER AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-2229
Country	:	US
Telephone Number	:	917-569-0027
Fax Number	:

Provider Business Practice Location Address
First Line	:	4064 BRUNER AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-2229
Country	:	US
Telephone Number	:	917-569-0027
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MR. GEORGE MINIX
Credential	:	RCS
Telephone Number	:	917-569-0027

Provider Enumeration Date	:	03/24/2011
Last Update Date	:	04/11/2011

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