Healthcare Provider Details

I. General information

NPI: 1043478605
Provider Name (Legal Business Name): LILLIAN KIM IVANSCO M.D., M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 01/10/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GLENLAKE PKWY
ATLANTA GA
30328-3473
US

IV. Provider business mailing address

3495 PIEDMONT RD NE
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 404-364-7285
  • Fax:
Mailing address:
  • Phone: 404-364-7285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD17668
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number04-37114
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number27713
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number53370
License Number StateCO
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number069869
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: