Healthcare Provider Details

I. General information

NPI: 1255600169
Provider Name (Legal Business Name): STEPHEN G HLADEK AA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MICCOSUKEE RD
TALLAHASSEE FL
32308-5054
US

IV. Provider business mailing address

1613 HARRISON PKWY SUITE 200
SUNRISE FL
33323-2896
US

V. Phone/Fax

Practice location:
  • Phone: 954-838-2588
  • Fax: 954-514-3979
Mailing address:
  • Phone: 954-838-2588
  • Fax: 954-514-3979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA111
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: