MEDICARE: INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	207RH0003X	Hematology & Oncology Physician		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	94890	OTHER	FL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851388128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC

Provider Business Mailing Address
First Line	:	9143 PHILIPS HWY
Second Line	:	STE 560
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-1348
Country	:	US
Telephone Number	:	904-363-2113
Fax Number	:	904-538-3672

Provider Business Practice Location Address
First Line	:	2 SHIRCLIFF WAY
Second Line	:	SUITE 800
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-4732
Country	:	US
Telephone Number	:	904-388-2619
Fax Number	:	904-388-0240

Authorized Official
Title or Position	:	CEO
Name	:	MR. ROBERT J PHELAN
Credential	:
Telephone Number	:	904-363-2113

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	05/24/2012

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