Provider Demographics
NPI:1659576577
Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Entity Type:Organization
Organization Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Other - Org Name:CANCER SPECIALIST OF NORTH FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
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:904-363-2606
Practice Address - Street 1:4203 BELFORT RD
Practice Address - Street 2:SUITE 215
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1409
Practice Address - Country:US
Practice Address - Phone:904-739-7779
Practice Address - Fax:904-739-7771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
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
FL94890OtherBCBS
FL273427325Medicaid
FL273427325Medicaid
FLK7038Medicare PIN