MEDICARE: DALE RAFAEL CHARNECO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	ME15741	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00121400	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	16812Y	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1740281781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALE RAFAEL CHARNECO

Provider Business Mailing Address
First Line	:	PO BOX 44008
Second Line	:	UFJP PROVIDER ENROLLMENT
City	:	JACKSONVILLE
State	:	FL
Zip	:	32231-4008
Country	:	US
Telephone Number	:	904-244-3660
Fax Number	:	904-244-3425

Provider Business Practice Location Address
First Line	:	2055 PROFESSIONAL CENTER DR
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4461
Country	:	US
Telephone Number	:	904-276-4500
Fax Number	:	904-276-4160

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2005
Last Update Date	:	01/15/2008

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Directions to “ DALE RAFAEL CHARNECO ” Practice Location

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