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General NPI Number Information
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NPI Number | 1598739831
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Entity Type | Organization
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Legal Business Name | PALM BEACH PEDIATRIC UROLOGY
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Dates
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Enumeration Date | 02/14/2006
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Last Update Date | 10/22/2013
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Provider Practice Location Address
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Address Line | 10301 HAGEN RANCH RD SUITE C130
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City | BOYNTON BEACH
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State | FL
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Zip | 33437
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Country | US
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Telephone | 561-736-7313
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Fax | 561-736-2309
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Provider Business Mailing Address
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Address Line | 10301 HAGEN RANCH RD SUITE C130
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City | BOYNTON BEACH
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State | FL
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Zip | 33437
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Country | US
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Telephone | 561-736-7313
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Fax | 561-736-2309
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHARLES E FLACK
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Credential | M.D.
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Telephone | 561-512-0614
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | ME599337
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License Number State | FL
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