Healthcare Provider Details

I. General information

NPI: 1811325913
Provider Name (Legal Business Name): JACOB HLAVACH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5831 BEE RIDGE RD STE 300
SARASOTA FL
34233-5090
US

IV. Provider business mailing address

5831 BEE RIDGE RD STE 300
SARASOTA FL
34233-5090
US

V. Phone/Fax

Practice location:
  • Phone: 941-378-5100
  • Fax: 941-378-2805
Mailing address:
  • Phone: 941-378-5100
  • Fax: 941-378-2805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9107443
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: