Healthcare Provider Details

I. General information

NPI: 1831197896
Provider Name (Legal Business Name): KELLY FLYNN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 DIMOCK ST
ROXBURY MA
02119-1029
US

IV. Provider business mailing address

15 BRACKETT ST
NEEDHAM MA
02492-1606
US

V. Phone/Fax

Practice location:
  • Phone: 617-442-8800
  • Fax: 617-541-8334
Mailing address:
  • Phone: 781-400-5296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036405
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number229645
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: