Basic Information
| Provider Information | |||||||||
| NPI: | 1558796151 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3599 UNIVERSITY BLVD S | ||||||||
| Address2: | SUITE 907 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043098680 | ||||||||
| FaxNumber: | 9043455841 | ||||||||
| Practice Location | |||||||||
| Address1: | 1677 EAGLE HARBOR PKWY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FLEMING ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320034802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042640004 | ||||||||
| FaxNumber: | 9042640009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2013 | ||||||||
| LastUpdateDate: | 09/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | PARYANI | ||||||||
| AuthorizedOfficialFirstName: | SHYAM | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9043098680 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 94980 | 01 | FL | BCBS | OTHER |