Basic Information
Provider Information | |||||||||
NPI: | 1639122989 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BARRY | ||||||||
FirstName: | LYNN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301 EXPLORER ST | ||||||||
Address2: |   | ||||||||
City: | GWINN | ||||||||
State: | MI | ||||||||
PostalCode: | 498412813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 1906346492 | ||||||||
FaxNumber: | 9063466474 | ||||||||
Practice Location | |||||||||
Address1: | 301 EXPLORER ST | ||||||||
Address2: |   | ||||||||
City: | GWINN | ||||||||
State: | MI | ||||||||
PostalCode: | 498412813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 1906346492 | ||||||||
FaxNumber: | 9063466474 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2006 | ||||||||
LastUpdateDate: | 04/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301047799 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 3045525 | 05 | MI |   | MEDICAID | 4877680 | 05 | MI |   | MEDICAID | 4777085 | 05 | MI |   | MEDICAID | 4878210 | 05 | MI |   | MEDICAID | 4509496 | 05 | MI |   | MEDICAID |