Basic Information
| Provider Information | |||||||||
| NPI: | 1558621912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YANTIS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4004 DUPONT CIRCLE #220 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930159 | ||||||||
| FaxNumber: | 5023123884 | ||||||||
| Practice Location | |||||||||
| Address1: | 4004 DUPONT CIR STE 220 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930159 | ||||||||
| FaxNumber: | 5028930159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 01078700A | IN | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | BP10044563 | TX | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 50401 | KY | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 7100475900 | 05 | KY | MEDICAID | 265400015 | 01 | IN | MEDICARE | OTHER | 01078700A | 01 | IN | LICENSE | OTHER | K240890 | 01 | KY | MEDICARE | OTHER | 50401 | 01 | KY | LICENSE | OTHER |