MEDICARE: TIMOTHY Y. MARYANOV M.D.

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	207T00000X	Neurological Surgery Physician	LL33444	SC
2	207T00000X	Neurological Surgery Physician	E7752	AR

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	:	1629298500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY Y. MARYANOV M.D.

Provider Business Mailing Address
First Line	:	9616 ROGERS AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5769
Country	:	US
Telephone Number	:	479-551-2127
Fax Number	:	479-439-8868

Provider Business Practice Location Address
First Line	:	9616 ROGERS AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5769
Country	:	US
Telephone Number	:	479-242-3310
Fax Number	:	479-439-8868

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

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	02/28/2023

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