Healthcare Provider Details

I. General information

NPI: 1942039060
Provider Name (Legal Business Name): BRIAN RUSSELL FLYNN SUBMARINE IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 CORMORANT RD
GROTON CT
06340-3113
US

IV. Provider business mailing address

122 CORMORANT RD
GROTON CT
06340-3113
US

V. Phone/Fax

Practice location:
  • Phone: 814-214-2394
  • Fax:
Mailing address:
  • Phone: 814-214-2394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: