Provider Demographics
NPI:1164450987
Name:FLACK, JOHN MARK (MD, MPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:FLACK
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19636
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9636
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-4735
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-4735
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-138254207R00000X, 207RH0005X, 207RH0005X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RH0005XAllopathic & Osteopathic PhysiciansInternal MedicineHypertension Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036138254Medicaid
IL036138254Medicaid
ILF400235241Medicare PIN