Provider Demographics
NPI:1245296979
Name:YETTER, TAD A (MD)
Entity type:Individual
Prefix:
First Name:TAD
Middle Name:A
Last Name:YETTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N PROMENADE ST
Mailing Address - Street 2:P O BOX 530
Mailing Address - City:HAVANA
Mailing Address - State:IL
Mailing Address - Zip Code:62644-1015
Mailing Address - Country:US
Mailing Address - Phone:309-543-6600
Mailing Address - Fax:309-543-2089
Practice Address - Street 1:615 N PROMENADE ST
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:IL
Practice Address - Zip Code:62644-1015
Practice Address - Country:US
Practice Address - Phone:309-543-6600
Practice Address - Fax:309-543-2089
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036079681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079681Medicaid
IL808700Medicare ID - Type UnspecifiedINTERNAL MEDICINE
IL036079681Medicaid