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General NPI Number Information
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NPI Number | 1205865433
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Entity Type | Organization
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Legal Business Name | INTER COMMUNITY CANCER INSTITUTE LLC
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Dates
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Enumeration Date | 07/01/2006
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Last Update Date | 04/29/2015
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Provider Practice Location Address
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Address Line | 1920 DON WICKHAM DR SUITE 130
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City | CLERMONT
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State | FL
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Zip | 34711-1918
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Country | US
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Telephone | 352-243-9709
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Fax | 352-243-8703
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Provider Business Mailing Address
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Address Line | 1920 DON WICKHAM DR STE 130
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City | CLERMONT
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State | FL
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Zip | 34711-1978
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Country | US
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Telephone | 352-243-9709
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Fax | 352-243-8703
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. HAL M JACOBSON
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Credential | MD
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Telephone | 352-243-9709
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0001X
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Taxonomy Name | Radiation Oncology Physician
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License Number |
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License Number State |
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