Basic Information
| Provider Information | |||||||||
| NPI: | 1043478605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IVANSCO | ||||||||
| FirstName: | LILLIAN | ||||||||
| MiddleName: | KIM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., M.P.H. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043647285 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20 GLENLAKE PKWY | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303283473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043647285 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD17668 | HI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 04-37114 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 27713 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 53370 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 069869 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 10026277500 | 05 | NE | MEDICAID | 10026277600 | 05 | NE | MEDICAID | 10026277700 | 05 | NE | MEDICAID | 10026277300 | 05 | NE | MEDICAID | 10026277400 | 05 | NE | MEDICAID | 10026277800 | 05 | NE | MEDICAID | 1043478605 | 05 | IA | MEDICAID | 66229006 | 05 | NM | MEDICAID | 929695 | 05 | AZ | MEDICAID | 1043478605 | 05 | WY | MEDICAID | 1043478605 | 05 | UT | MEDICAID | 1043478605 | 05 | MT | MEDICAID | 201098570A | 05 | KS | MEDICAID | 10025709000 | 05 | NE | MEDICAID | 79754571 | 05 | CO | MEDICAID |