=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154302610
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY CORCORAN FLYNN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2005
-----------------------------------------------------
Last Update Date | 09/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 WELLESLEY TRADE LN
-----------------------------------------------------
City | CARY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27519-5576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-363-7546
-----------------------------------------------------
Fax | 919-363-3616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 WELLESLEY TRADE LN
-----------------------------------------------------
City | CARY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27519-5576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-363-7546
-----------------------------------------------------
Fax | 919-363-3616
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 29569
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | 29569
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------