Basic Information
| Provider Information | |||||||||
| NPI: | 1225234404 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE CYBERKNIFE CENTER AT CENTRAL FLORIDA REGIONAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19675 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322459675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463338 | ||||||||
| FaxNumber: | 9043460815 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 N MANGOUSTINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327711017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078337518 | ||||||||
| FaxNumber: | 4078337514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | PARYANI | ||||||||
| AuthorizedOfficialFirstName: | SHYAM | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9043463338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | DC6938 | 01 | FL | MEDICARE RAILROAD | OTHER | 94890 | 01 | FL | BCBS | OTHER |