Provider Demographics
NPI:1235396789
Name:CHARLES R SCHALLOP MD P A
Entity Type:Organization
Organization Name:CHARLES R SCHALLOP MD P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCHALLOP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-630-6939
Mailing Address - Street 1:PO BOX 30308
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33420-0308
Mailing Address - Country:US
Mailing Address - Phone:561-630-6939
Mailing Address - Fax:
Practice Address - Street 1:500 UNIVERSITY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-2773
Practice Address - Country:US
Practice Address - Phone:561-630-6939
Practice Address - Fax:561-630-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0059068174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055367100Medicaid
FL055367100Medicaid