=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417962945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA B. KLISOVIC M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2006
-----------------------------------------------------
Last Update Date | 08/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1365 CLIFTON RD NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30322-1280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-778-3932
-----------------------------------------------------
Fax | 404-778-4755
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1365 CLIFTON RD NE STE C5004
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30322-1013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-778-3932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0000X
-----------------------------------------------------
Taxonomy Name | Hematology (Internal Medicine) Physician
-----------------------------------------------------
License Number | 35079648
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number | 78405
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------