Basic Information
| Provider Information | |||||||||
| NPI: | 1821085101 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED COMMUNITY ONCOLOGY NETWORK LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ICON ONCOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3599 UNIVERSITY BLVD S | ||||||||
| Address2: | SUITE 805 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043098680 | ||||||||
| FaxNumber: | 9043455841 | ||||||||
| Practice Location | |||||||||
| Address1: | 2161 KINGSLEY AVENUE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042762303 | ||||||||
| FaxNumber: | 9042763660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 11/28/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARSLAND | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9042762303 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | FL | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 94870 | 01 | FL | BCBS | OTHER | 273427307 | 05 | FL | MEDICAID |