Healthcare Provider Details

I. General information

NPI: 1629070271
Provider Name (Legal Business Name): LISA M FLYNN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 12/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 JOHN R SUITE 615
DETROIT MI
48201-2020
US

IV. Provider business mailing address

1420 STEPHENSON HWY SUITE 400-CREDENTIALING
TROY MI
48083-1189
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4195
  • Fax: 313-993-8669
Mailing address:
  • Phone: 248-581-5974
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301061622
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301061622
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: