Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RH0000X | Hematologist | 35079648 | OH |
Y | 207RX0202X | Medical Oncology | 78405 | GA |
NPI | 1417962945 |
---|---|
Provider Name | Rebecca B. Klisovic |
First Address | Atlanta, GA 30322-1013 |
Second Address | Atlanta, GA 30322-1280 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2006 |
Last Update Date | 21/08/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2282239 | (05) | OH |
H11974 | (02) | OH |