Provider Demographics
NPI:1598739831
Name:PALM BEACH PEDIATRIC UROLOGY
Entity Type:Organization
Organization Name:PALM BEACH PEDIATRIC UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:FLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-512-0614
Mailing Address - Street 1:10301 HAGEN RANCH RD
Mailing Address - Street 2:SUITE C130
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437
Mailing Address - Country:US
Mailing Address - Phone:561-736-7313
Mailing Address - Fax:561-736-2309
Practice Address - Street 1:10301 HAGEN RANCH RD
Practice Address - Street 2:SUITE C130
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437
Practice Address - Country:US
Practice Address - Phone:561-736-7313
Practice Address - Fax:561-736-2309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME599337208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2032607OtherAETNA HMO
FL272189900Medicaid
FL4611456OtherAETNA NON-HMO
FL1755943OtherCIGNA
FL5962OtherNHP
FL103690OtherAVMED
FL204200OtherAMERIGROUP
FL12475OtherBCBS
FL26943OtherWELLCARE