1467449785 NPI number — INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC

Table of content: (NPI 1467449785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467449785 NPI number — INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467449785
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9143 PHILIPS HWY
Provider Second Line Business Mailing Address:
STE 560
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-1348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-363-2113
Provider Business Mailing Address Fax Number:
904-538-3672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1375 ROBERTS DR
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
JACKSONVILLE BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32250-3210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-997-3800
Provider Business Practice Location Address Fax Number:
904-997-3899
Provider Enumeration Date:
10/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PHELAN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
904-363-2113

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 94890 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 273427318 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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