Healthcare Provider Details

I. General information

NPI: 1720310733
Provider Name (Legal Business Name): INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 VILLAGE WAY
ORANGE PARK FL
32073-5263
US

IV. Provider business mailing address

9143 PHILIPS HWY STE 560
JACKSONVILLE FL
32256-1369
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-8418
  • Fax: 904-264-9692
Mailing address:
  • Phone: 904-363-7453
  • Fax: 904-538-3672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME59868
License Number StateFL

VIII. Authorized Official

Name: ROBERT J PHELAN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 904-363-2113