Provider Demographics
NPI:1114216660
Name:SOVEREIGN MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SOVEREIGN MEDICAL GROUP LLC
Other - Org Name:JERSEY CITY RADIATION THERAPY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:VARDARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-880-7580
Mailing Address - Street 1:631 GRAND STREET
Mailing Address - Street 2:SUITE 1-1
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304
Mailing Address - Country:US
Mailing Address - Phone:201-880-7580
Mailing Address - Fax:201-880-7585
Practice Address - Street 1:631 GRAND STREET
Practice Address - Street 2:SUITE 1-1
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304
Practice Address - Country:US
Practice Address - Phone:201-880-7580
Practice Address - Fax:201-880-7585
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOVEREIGN MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-06
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty