Healthcare Provider Details

I. General information

NPI: 1578738936
Provider Name (Legal Business Name): ROBERT J SIVAK, M.D., LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 S MILL AVE SUITE 160
TEMPE AZ
85282-6757
US

IV. Provider business mailing address

4600 S MILL AVE STE 160
TEMPE AZ
85282-6758
US

V. Phone/Fax

Practice location:
  • Phone: 480-345-1200
  • Fax: 480-345-1281
Mailing address:
  • Phone: 480-345-1200
  • Fax: 480-345-1281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number12253
License Number StateAZ

VIII. Authorized Official

Name: DR. ROBERT JOHN SIVAK
Title or Position: PRESIDENT
Credential: MD
Phone: 480-345-1200