Healthcare Provider Details

I. General information

NPI: 1104114230
Provider Name (Legal Business Name): JACOB GEORGE FLYNN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MEDICAL CAMPUS DR
TRAVERSE CITY MI
49684-7823
US

IV. Provider business mailing address

1400 MEDICAL CAMPUS DR
TRAVERSE CITY MI
49684-7823
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-8000
  • Fax: 231-935-8099
Mailing address:
  • Phone: 231-935-8000
  • Fax: 231-935-8099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301099491
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: