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General NPI Number Information
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NPI Number | 1043478605
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Entity Type | Individual
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Provider Name | LILLIAN KIM IVANSCO M.D., M.P.H.
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Gender | Female
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Dates
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Enumeration Date | 05/29/2008
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Last Update Date | 01/10/2022
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Provider Practice Location Address
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Address Line | 20 GLENLAKE PKWY
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City | ATLANTA
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State | GA
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Zip | 30328-3473
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Country | US
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Telephone | 404-364-7285
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Fax |
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Provider Business Mailing Address
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Address Line | 3495 PIEDMONT RD NE
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City | ATLANTA
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State | GA
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Zip | 30305-1717
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Country | US
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Telephone | 404-364-7285
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | MD17668
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License Number State | HI
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 04-37114
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License Number State | KS
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 27713
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License Number State | NE
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Taxonomy #4
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 53370
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License Number State | CO
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Taxonomy #5
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 069869
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License Number State | GA
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