Healthcare Provider Details

I. General information

NPI: 1861427155
Provider Name (Legal Business Name): INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEALTH PARK BLVD SUITE 1008
ST AUGUSTINE FL
32086-3707
US

IV. Provider business mailing address

PO BOX 19675
JACKSONVILLE FL
32245-9675
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-5189
  • Fax: 904-824-9109
Mailing address:
  • Phone: 904-309-8680
  • Fax: 904-345-5847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHYAM B PARYANI
Title or Position: DIRECTOR
Credential: MD
Phone: 904-309-8680