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	207RH0003X	Hematology & Oncology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	94870	OTHER	FL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932196250
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	:	904-538-7453

Provider Business Practice Location Address
First Line	:	14546 OLD SAINT AUGUSTINE RD
Second Line	:	BLDG 1 STE 317
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-5468
Country	:	US
Telephone Number	:	904-260-9445
Fax Number	:	904-260-0005

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

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

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Directions to “INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC ” Practice Location

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