1043478605 NPI number — DR. LILLIAN KIM IVANSCO M.D., M.P.H.

Table of content: DR. LILLIAN KIM IVANSCO M.D., M.P.H. (NPI 1043478605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043478605 NPI number — DR. LILLIAN KIM IVANSCO M.D., M.P.H.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IVANSCO
Provider First Name:
LILLIAN
Provider Middle Name:
KIM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., M.P.H.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043478605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3495 PIEDMONT RD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30305-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-364-7285
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 GLENLAKE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30328-3473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-364-7285
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  MD17668 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 04-37114 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 27713 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 53370 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 069869 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10026277500 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026277600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026277700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026277300 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026277400 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026277800 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1043478605 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 66229006 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 929695 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1043478605 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1043478605 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1043478605 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201098570A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025709000 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 79754571 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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