Provider Demographics
NPI:1447524772
Name:REGIONAL CANCER CARE ASSOCIATES LLC
Entity type:Organization
Organization Name:REGIONAL CANCER CARE ASSOCIATES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
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
Mailing Address - Country:US
Mailing Address - Phone:732-390-7750
Mailing Address - Fax:732-390-7725
Practice Address - Street 1:J2 BRIER HILL CT
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816
Practice Address - Country:US
Practice Address - Phone:732-390-7750
Practice Address - Fax:732-390-7725
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGIONAL CANCER CARE ASSOCIATES LCC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-05
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6682390003Medicare NSC