Provider Demographics
NPI:1649574500
Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Entity Type:Organization
Organization Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Other - Org Name:KASRAEIAN UROLOGY DIVISON OF ICON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:KASRAEIAN UROLOGY DIVISION MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KASRAEIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-727-7955
Mailing Address - Street 1:6269 BEACH BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-2768
Mailing Address - Country:US
Mailing Address - Phone:904-727-7955
Mailing Address - Fax:877-406-4796
Practice Address - Street 1:6269 BEACH BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2768
Practice Address - Country:US
Practice Address - Phone:904-727-7955
Practice Address - Fax:904-727-7976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273427300Medicaid
FL273427300Medicaid