Provider Demographics
NPI:1043365588
Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Entity Type:Organization
Organization Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Other - Org Name:CANCER CENTER OF PALM COAST
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:PHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-363-2113
Mailing Address - Street 1:9143 PHILIPS HWY
Mailing Address - Street 2:SUITE 560
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-1348
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:904-538-3672
Practice Address - Street 1:9 PINE CONE DR
Practice Address - Street 2:SUITE 108
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8686
Practice Address - Country:US
Practice Address - Phone:386-445-7334
Practice Address - Fax:386-445-7389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273427324Medicaid
FL94890OtherBCBS
FLDC6938Medicare PIN
FL273427324Medicaid