Provider Demographics
NPI:1720310733
Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Entity type:Organization
Organization Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 STE 560
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-1369
Mailing Address - Country:US
Mailing Address - Phone:904-363-7453
Mailing Address - Fax:904-538-3672
Practice Address - Street 1:1715 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5263
Practice Address - Country:US
Practice Address - Phone:904-264-8418
Practice Address - Fax:904-264-9692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59868208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty