1386790988 NPI number — ANN DEBOURCY FLYNN MD

Table of content: ANN DEBOURCY FLYNN MD (NPI 1386790988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386790988 NPI number — ANN DEBOURCY FLYNN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLYNN
Provider First Name:
ANN
Provider Middle Name:
DEBOURCY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEBOURCY
Provider Other First Name:
ANN
Provider Other Middle Name:
CHRISTINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386790988
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 N 1900 E
Provider Second Line Business Mailing Address:
SOM 4R118
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84132-0002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-581-7803
Provider Business Mailing Address Fax Number:
801-581-7476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 N 1900 E
Provider Second Line Business Practice Location Address:
SOM 4R118
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84132-0002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-581-7803
Provider Business Practice Location Address Fax Number:
801-581-7476
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  01071372A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 01071372A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 8525129-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000772850 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P01163477 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201078440 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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