Healthcare Provider Details

I. General information

NPI: 1497729727
Provider Name (Legal Business Name): CHARLES EDWARD FLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10301 HAGEN RANCH RD SUITE C130
BOYNTON BEACH FL
33437
US

IV. Provider business mailing address

1300 SAWGRASS CORPORATE PKWY STE 200
SUNRISE FL
33323-2823
US

V. Phone/Fax

Practice location:
  • Phone: 561-736-7313
  • Fax: 561-736-2309
Mailing address:
  • Phone: 800-243-3839
  • Fax: 855-527-5510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number0101273176
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberME59937
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberTP103
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: