Basic Information
Provider Information | |||||||||
NPI: | 1154302610 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLYNN | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | CORCORAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 WELLESLEY TRADE LN | ||||||||
Address2: |   | ||||||||
City: | CARY | ||||||||
State: | NC | ||||||||
PostalCode: | 275195576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9193637546 | ||||||||
FaxNumber: | 9193633616 | ||||||||
Practice Location | |||||||||
Address1: | 200 WELLESLEY TRADE LN | ||||||||
Address2: |   | ||||||||
City: | CARY | ||||||||
State: | NC | ||||||||
PostalCode: | 275195576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9193637546 | ||||||||
FaxNumber: | 9193633616 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2005 | ||||||||
LastUpdateDate: | 09/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 29569 | NC | N |   | Allopathic & Osteopathic Physicians | Dermatology |   | 207ND0101X | 29569 | NC | Y |   | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
ID | Type | State | Issuer | Description | 22635 | 01 | NC | DOCTORS HEALTH PLAN | OTHER | 2549406 | 01 |   | AETNA HMO | OTHER | 4230459 | 01 |   | AETNA PPO | OTHER | 42294 | 01 |   | PARTNERS | OTHER | 89128G2 | 05 | NC |   | MEDICAID | 3108348002 | 01 | NC | CIGNA HEALTHCARE HMO | OTHER | 562070218F | 01 | NC | CIGNA HEALTHCARE | OTHER | 0357057 | 01 |   | UNITED HEALTHCARE | OTHER | 128G2 | 01 | NC | BCBS | OTHER | 290914 | 01 |   | MAMSI/ALLIANCE | OTHER | A6811 | 01 |   | MEDCOST | OTHER |