Healthcare Provider Details

I. General information

NPI: 1144495920
Provider Name (Legal Business Name): INTERVENTIONAL CARDIOVASCULAR ASSOCIATES GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE
HACKENSACK NJ
07601-1997
US

IV. Provider business mailing address

20 PROSPECT AVE
HACKENSACK NJ
07601-1997
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-1444
  • Fax: 201-646-9531
Mailing address:
  • Phone: 201-996-1444
  • Fax: 201-646-9531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA06656300
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. ROGER HOWARD COLETTI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 201-996-1444