Healthcare Provider Details

I. General information

NPI: 1932196250
Provider Name (Legal Business Name): INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 05/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14546 OLD SAINT AUGUSTINE RD BLDG 1 STE 317
JACKSONVILLE FL
32258-5468
US

IV. Provider business mailing address

9143 PHILIPS HWY STE 560
JACKSONVILLE FL
32256-1348
US

V. Phone/Fax

Practice location:
  • Phone: 904-260-9445
  • Fax: 904-260-0005
Mailing address:
  • Phone: 904-363-2113
  • Fax: 904-538-7453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT PHELAN
Title or Position: CEO
Credential:
Phone: 904-363-2113