Basic Information
Provider Information | |||||||||
NPI: | 1669475018 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLINT | ||||||||
FirstName: | MARY JO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KOPPENHAVER | ||||||||
OtherFirstName: | MARY JO | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 79 HIGHWAY 51 S | ||||||||
Address2: |   | ||||||||
City: | RIPLEY | ||||||||
State: | TN | ||||||||
PostalCode: | 380634580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316358189 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 656 KIMBERLY DR | ||||||||
Address2: |   | ||||||||
City: | HENDERSON | ||||||||
State: | TN | ||||||||
PostalCode: | 383402007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7319895180 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2005 | ||||||||
LastUpdateDate: | 08/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0425097 | KS | N |   | Other Service Providers | Specialist |   | 208000000X | 63648 | TN | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.