Basic Information
| Provider Information | |||||||||
| NPI: | 1417962945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLISOVIC | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1365 CLIFTON RD NE STE C5004 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047783932 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1365 CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047783932 | ||||||||
| FaxNumber: | 4047784755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 08/21/2017 | ||||||||
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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 | 207RH0000X | 35079648 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | 78405 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 2282239 | 05 | OH | MEDICAID |