Provider Demographics
NPI:1043478605
Name:IVANSCO, LILLIAN KIM (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:LILLIAN
Middle Name:KIM
Last Name:IVANSCO
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-364-7285
Mailing Address - Fax:
Practice Address - Street 1:20 GLENLAKE PKWY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3473
Practice Address - Country:US
Practice Address - Phone:404-364-7285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD176682085R0202X
KS04-371142085R0202X
NE277132085R0202X
CO533702085R0202X
GA0698692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026277500Medicaid
NE10026277600Medicaid
NE10026277700Medicaid
NE10026277300Medicaid
NE10026277400Medicaid
NE10026277800Medicaid
IA1043478605Medicaid
NM66229006Medicaid
AZ929695Medicaid
WY1043478605Medicaid
UT1043478605Medicaid
MT1043478605Medicaid
KS201098570AMedicaid
NE10025709000Medicaid
CO79754571Medicaid
NE840897126-00Medicare PIN
CO349741ZLJ3Medicare PIN
CO349741YQPGMedicare PIN
IA1043478605Medicaid
CO79754571Medicaid
NE10026277300Medicaid
NE84059792913Medicare PIN
KS201098570AMedicaid
MT1043478605Medicaid
NENA2517057Medicare PIN
CO349741YQ33Medicare PIN
NE10026277400Medicaid
KS111257078Medicare PIN
COP01384845Medicare PIN