Healthcare Provider Details

I. General information

NPI: 1134565997
Provider Name (Legal Business Name): REGIONAL CANCER CARE ASSOCIATES AT THE JOHN THEURER CANCER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 2ND ST
HACKENSACK NJ
07601-2105
US

IV. Provider business mailing address

112 CADMUS AVE
ELMWOOD PARK NJ
07407-2500
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-5900
  • Fax:
Mailing address:
  • Phone: 201-314-3665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00435700
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ANDRE GOY
Title or Position: DIRECTOR
Credential: M.D.
Phone: 551-996-5900