MEDICARE: ADA BLIVEN APN

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	363LA2100X	Acute Care Nurse Practitioner	26NJ00115400	NJ

General Provider Information

NPI Number	:	1275687287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADA BLIVEN APN

Provider Business Mailing Address
First Line	:	28 HOLLANDER ST
Second Line	:
City	:	SOUTH RIVER
State	:	NJ
Zip	:	08882-1102
Country	:	US
Telephone Number	:	732-238-2492
Fax Number	:	732-235-8149

Provider Business Practice Location Address
First Line	:	125 PATERSON ST
Second Line	:	SUITE # 6129
City	:	NEW BRUNSWICK
State	:	NJ
Zip	:	08901-1962
Country	:	US
Telephone Number	:	732-235-7005
Fax Number	:	732-235-8149

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	07/08/2007

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