1497729727 NPI number — CHARLES EDWARD FLACK MD

Table of content: DORRIE VARLEY-BARRETT (NPI 1669251187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497729727 NPI number — CHARLES EDWARD FLACK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLACK
Provider First Name:
CHARLES
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497729727
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 SAWGRASS CORPORATE PKWY STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33323-2823
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-243-3839
Provider Business Mailing Address Fax Number:
855-527-5510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10301 HAGEN RANCH RD
Provider Second Line Business Practice Location Address:
SUITE C130
Provider Business Practice Location Address City Name:
BOYNTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-736-7313
Provider Business Practice Location Address Fax Number:
561-736-2309
Provider Enumeration Date:
02/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2088P0231X , with the licence number:  0101273176 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2088P0231X , with the licence number: ME59937 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2088P0231X , with the licence number: TP103 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 204200 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 26943 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 054273300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103690 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2032607 . This is a "AETNA HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4611456 . This is a "AETNA NON-HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 26943 . This is a "STAYWELL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5962 . This is a "NHP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 12475 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1755943 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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