Provider Demographics
NPI:1508319039
Name:REGIONAL CANCER CARE ASSOCIATES LLC
Entity Type:Organization
Organization Name:REGIONAL CANCER CARE ASSOCIATES LLC
Other - Org Name:NORTHERN NEW JERSEY CANCER ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:LICITRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:732-390-7750
Mailing Address - Street 1:J2 BRIER HILL CT
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-3340
Mailing Address - Country:US
Mailing Address - Phone:732-390-7750
Mailing Address - Fax:732-254-1048
Practice Address - Street 1:34-36 PROGRESS ST
Practice Address - Street 2:SUITE B-2
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1197
Practice Address - Country:US
Practice Address - Phone:908-757-9696
Practice Address - Fax:908-757-9721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6682390022OtherMEDICARE NSC DMERC#