Provider Demographics
NPI:1588674568
Name:FLYNN DERMATOLOGY PA
Entity Type:Organization
Organization Name:FLYNN DERMATOLOGY PA
Other - Org Name:FAMILY DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:K
Authorized Official - Last Name:FLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-791-0840
Mailing Address - Street 1:5603 DURALEIGH RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2688
Mailing Address - Country:US
Mailing Address - Phone:919-791-0840
Mailing Address - Fax:919-791-0911
Practice Address - Street 1:5603 DURALEIGH RD
Practice Address - Street 2:SUITE 111
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-2688
Practice Address - Country:US
Practice Address - Phone:919-791-0840
Practice Address - Fax:919-791-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2333971Medicare ID - Type UnspecifiedGRP MEDICARE NUMBER