Basic Information
| Provider Information | |||||||||
| NPI: | 1497729727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLACK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 SAWGRASS CORPORATE PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 8555275510 | ||||||||
| Practice Location | |||||||||
| Address1: | 10301 HAGEN RANCH RD | ||||||||
| Address2: | SUITE C130 | ||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617367313 | ||||||||
| FaxNumber: | 5617362309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2088P0231X | ME59937 | FL | N | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 2088P0231X | TP103 | KY | N | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 2088P0231X | 0101273176 | VA | Y | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
| ID | Type | State | Issuer | Description | 204200 | 01 | FL | AMERIGROUP | OTHER | 5962 | 01 | FL | NHP | OTHER | 054273300 | 05 | FL | MEDICAID | 103690 | 01 | FL | AVMED | OTHER | 12475 | 01 | FL | BCBS | OTHER | 1755943 | 01 | FL | CIGNA | OTHER | 26943 | 01 | FL | STAYWELL | OTHER | 4611456 | 01 | FL | AETNA NON-HMO | OTHER | 2032607 | 01 | FL | AETNA HMO | OTHER | 26943 | 01 | FL | WELLCARE | OTHER |