Basic Information
| Provider Information | |||||||||
| NPI: | 1598739831 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALM BEACH PEDIATRIC UROLOGY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10301 HAGEN RANCH RD | ||||||||
| Address2: | SUITE C130 | ||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617367313 | ||||||||
| FaxNumber: | 5617362309 | ||||||||
| 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: | 10/22/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLACK | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5615120614 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | ME599337 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 2032607 | 01 | FL | AETNA HMO | OTHER | 272189900 | 05 | FL | MEDICAID | 4611456 | 01 | FL | AETNA NON-HMO | OTHER | 1755943 | 01 | FL | CIGNA | OTHER | 5962 | 01 | FL | NHP | OTHER | 103690 | 01 | FL | AVMED | OTHER | 204200 | 01 | FL | AMERIGROUP | OTHER | 12475 | 01 | FL | BCBS | OTHER | 26943 | 01 | FL | WELLCARE | OTHER |