1497729727 NPI number — CHARLES EDWARD FLACK MD

Table of content: CHARLES EDWARD FLACK MD (NPI 1497729727)

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:
09/12/2022
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:  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" .
  • 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" .

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: 5962 . This is a "NHP" 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: 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".
  • Identifier: 26943 . This is a "STAYWELL" 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: 2032607 . This is a "AETNA HMO" 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".




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