Healthcare Provider Details

I. General information

NPI: 1174566038
Provider Name (Legal Business Name): TIMOTHY M FLYNN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5665 N JUNCTION WAY
DAVIS JUNCTION IL
61020
US

IV. Provider business mailing address

PO BOX 78866
MILWAUKEE WI
53278-8866
US

V. Phone/Fax

Practice location:
  • Phone: 779-696-9200
  • Fax:
Mailing address:
  • Phone: 779-696-7150
  • Fax: 779-696-7342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036102806
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: