Provider Demographics
NPI:1649220690
Name:SPARTA CANCER CENTER LLC
Entity Type:Organization
Organization Name:SPARTA CANCER CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-726-0005
Mailing Address - Street 1:712 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOOSIC
Mailing Address - State:PA
Mailing Address - Zip Code:18507-1094
Mailing Address - Country:US
Mailing Address - Phone:570-451-3910
Mailing Address - Fax:570-451-3236
Practice Address - Street 1:89 SPARTA AVE
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1777
Practice Address - Country:US
Practice Address - Phone:973-726-0005
Practice Address - Fax:973-726-4668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0116441Medicaid
NY02834664Medicaid
PA101877562Medicaid
PA101877562Medicaid