Provider Demographics
NPI:1821085101
Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Entity Type:Organization
Organization Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Other - Org Name:ICON ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARSLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-276-2303
Mailing Address - Street 1:3599 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 805
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216
Mailing Address - Country:US
Mailing Address - Phone:904-309-8680
Mailing Address - Fax:904-345-5841
Practice Address - Street 1:2161 KINGSLEY AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-276-2303
Practice Address - Fax:904-276-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2012-11-28
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
FL94870OtherBCBS
FL273427307Medicaid
FL5599740005Medicare NSC
FLK7038Medicare PIN
FLDC6938Medicare PIN