Organization
INTERCOMMUNITY CANCER CENTER - LADY LAKE CAMPUS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
HAL M JACOBSON (MEDICAL DIRECTOR)
(352) 326-2224
Entity
Organization
Contact information
Practice address
922 ROLLING ACRES RD, LADY LAKE, FL 32159-5022
(352) 753-6198
(352) 326-8335
Mailing address
PO BOX 863359, ORLANDO, FL 32886-3359
(352) 326-2224
(352) 326-8335
Taxonomy
Speciality
Code
Description
License number
State
2085R0001X
Radiation Oncology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
273918600
—
FL
01
—
DE8303
RR MEDICARE
FL
Enumeration date
09/20/2005
Last updated
01/30/2012
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