Lillian Kim Ivansco, M.D., M.P.H.

Primary specialty

Diagnostic Radiology PhysicianTaxonomy code 2085R0202X

License

069869 Issued in GA

Practice address

20 Glenlake Pkwy
Atlanta, GA 30328-3473

Phone

(404) 364-7285

NPI assigned

May 29, 2008

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 5

Addresses

Other identifiers 15

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Diagnostic Radiology

Education

Emory University School of Medicine, 2008

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

The Southeast Permanente Medical GroupGroup PAC ID 6204829013, 823 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• The Southeast Permanente Medical Group

  • Internal Medicine Physician
  • Atlanta, GA
  • NPI 1245266956
  Medicare reassignment Care Compare group
• Emory Medical Care Foundation Inc

  • Internal Medicine Physician
  • Atlanta, GA
  • NPI 1063452381
  Medicare reassignment NPD
• The Emory Clinic Inc

  • Internal Medicine Physician
  • Atlanta, GA
  • NPI 1396798229

  Diagnostic Radiology

  Medicare reassignment NPD
• Emory Medical Care Foundation Inc

  • Diagnostic Radiology Physician
  • Atlanta, GA
  • NPI 1225294739
  NPD
• Gunnison Valley Hospital

  • Primary Care Clinic/Center
  • Gunnison, CO
  • NPI 1578997284

  Diagnostic Radiology

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1212019200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1641772800000",
    "number": "1043478605",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3495 PIEDMONT RD NE",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303051717",
            "telephone_number": "404-364-7285"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20 GLENLAKE PKWY",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303283473",
            "telephone_number": "404-364-7285"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "IVANSCO",
        "first_name": "LILLIAN",
        "middle_name": "KIM",
        "name_prefix": "Dr.",
        "credential": "M.D., M.P.H.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2008-05-29",
        "last_updated": "2022-01-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "HI",
            "license": "MD17668",
            "primary": false
        },
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "KS",
            "license": "04-37114",
            "primary": false
        },
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "NE",
            "license": "27713",
            "primary": false
        },
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "CO",
            "license": "53370",
            "primary": false
        },
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "GA",
            "license": "069869",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10026277500",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10026277600",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10026277700",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10026277300",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10026277400",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10026277800",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1043478605",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "66229006",
            "state": "NM"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "929695",
            "state": "AZ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1043478605",
            "state": "WY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1043478605",
            "state": "UT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1043478605",
            "state": "MT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201098570A",
            "state": "KS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10025709000",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "79754571",
            "state": "CO"
        }
    ],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepiceast.kp.org:14430/Interconnect-prodgam/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/ceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "20 Glenlake Pkwy",
            "city": "Atlanta",
            "state": "GA",
            "country_code": "US",
            "postal_code": "303283473",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Diagnostic Radiology Physician in Atlanta, GA
• Providers in Atlanta, GA by specialty
• Diagnostic Radiology Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 10, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.