Provider Demographics
NPI:1336136654
Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Entity Type:Organization
Organization Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Other - Org Name:CANCER CARE SPECIALISTS OF NORTH FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
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:STE 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 SAN BARTOLA DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5767
Practice Address - Country:US
Practice Address - Phone:904-825-4500
Practice Address - Fax:904-825-3672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RH0003X
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273427309Medicaid
FL94890OtherBCBS
FL273427309Medicaid
FLDC6938Medicare PIN
FL5599740007Medicare NSC