MEDICARE: INNOVATIVE VASCULAR GROUP

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	174400000X	Specialist	25MA06756800	NJ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	DC4342	OTHER	NJ	RAILROAD MEDICARE GROUP#

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2371188001	OTHER	NJ	AMERIHEALTH GROUP #

General Provider Information

NPI Number	:	1477591006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE VASCULAR GROUP

Provider Business Mailing Address
First Line	:	4 CRAPE MYRTLE DR
Second Line	:
City	:	HOLMDEL
State	:	NJ
Zip	:	07733-1529
Country	:	US
Telephone Number	:	732-380-1222
Fax Number	:

Provider Business Practice Location Address
First Line	:	142 HIGHWAY 35
Second Line	:	SUITE 106A
City	:	EATONTOWN
State	:	NJ
Zip	:	07724-3427
Country	:	US
Telephone Number	:	732-380-1222
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ALFONSO CIERVO
Credential	:	MD
Telephone Number	:	732-380-1222

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	09/13/2007

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Directions to “INNOVATIVE VASCULAR GROUP ” Practice Location

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