Basic Information
| Provider Information | |||||||||
| NPI: | 1407096183 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLORIDA RADIATION ONCOLOGY GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19675 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322459675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043098680 | ||||||||
| FaxNumber: | 9043455841 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 LOMAX ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044832310 | ||||||||
| FaxNumber: | 9044832313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2009 | ||||||||
| LastUpdateDate: | 07/31/2012 | ||||||||
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| AuthorizedOfficialLastName: | PARYANI | ||||||||
| AuthorizedOfficialFirstName: | SHYAM | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9043098680 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 273427327 | 05 | FL | MEDICAID | 94890 | 01 | FL | BCBS | OTHER | DC6938 | 01 | FL | RAILROAD MEDICARE | OTHER |