MEDICARE: YAN V YATSYNOVICH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	64321	TN
2	207RC0000X	Cardiovascular Disease Physician	64321	TN
3	207UN0901X	Nuclear Cardiology Physician	64321	TN
4	207RI0011X	Interventional Cardiology Physician	64321	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427445071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YAN V YATSYNOVICH MD

Provider Business Mailing Address
First Line	:	140 W 7TH ST
Second Line	:
City	:	COOKEVILLE
State	:	TN
Zip	:	38501-1726
Country	:	US
Telephone Number	:	931-783-5582
Fax Number	:

Provider Business Practice Location Address
First Line	:	228 W 4TH ST
Second Line	:
City	:	COOKEVILLE
State	:	TN
Zip	:	38501-2488
Country	:	US
Telephone Number	:	931-372-0405
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2015
Last Update Date	:	09/26/2022

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