Provider Demographics
NPI:1194896266
Name:FLYNN, RICHARD JOHN JR (PT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JOHN
Last Name:FLYNN
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:8 CATERHAM LN
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1945
Mailing Address - Country:US
Mailing Address - Phone:631-689-5775
Mailing Address - Fax:
Practice Address - Street 1:356 MIDDLE COUNTRY RD
Practice Address - Street 2:SECOND FLR STE 210
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-4432
Practice Address - Country:US
Practice Address - Phone:631-716-2700
Practice Address - Fax:631-716-2782
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY014526225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY650026123Medicare PIN
NYQ44073Medicare PIN
NYQ44071Medicare PIN
NYQ44072Medicare PIN