Provider Demographics
NPI:1215963061
Name:FLYNN, ETHAN ALEXANDER (MD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:ALEXANDER
Last Name:FLYNN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:215 DAWES AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-7349
Mailing Address - Country:US
Mailing Address - Phone:413-447-2567
Mailing Address - Fax:413-447-2097
Practice Address - Street 1:LAB BERKSHIRE MED CTR
Practice Address - Street 2:725 NORTH ST
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201
Practice Address - Country:US
Practice Address - Phone:413-447-2567
Practice Address - Fax:413-447-2097
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223784207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ28642OtherMASS BS/BS
MA2101807Medicaid
MAJ28642OtherMASS BS/BS
MAI40533Medicare UPIN