Provider Demographics
NPI:1629070271
Name:FLYNN, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:FLYNN
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5974
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:4160 JOHN R
Practice Address - Street 2:SUITE 615
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2020
Practice Address - Country:US
Practice Address - Phone:313-745-4195
Practice Address - Fax:313-993-8669
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2013-12-27
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Provider Licenses
StateLicense IDTaxonomies
MI4301061622208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G91044Medicare UPIN
OH 26358-021Medicare ID - Type Unspecified
MI0P30630776Medicare PIN