Provider Demographics
NPI:1477606614
Name:FLACK, RONALD J (NP)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:J
Last Name:FLACK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1978
Mailing Address - Country:US
Mailing Address - Phone:517-782-8142
Mailing Address - Fax:517-782-0765
Practice Address - Street 1:762 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1978
Practice Address - Country:US
Practice Address - Phone:517-782-8142
Practice Address - Fax:517-782-0765
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704149271363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI16789OtherHEALTH PLAN OF MICHIGAN
MI4733213Medicaid
MI4733213Medicaid
MI16789OtherHEALTH PLAN OF MICHIGAN
MI4354122Medicare UPIN