Healthcare Provider Details

I. General information

NPI: 1124068176
Provider Name (Legal Business Name): ROBERT J HLAVAC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 INNOVATION DRIVE
MILWAUKEE WI
53226
US

IV. Provider business mailing address

1001 W GLEN OAKS LN SUITE 105
MEQUON WI
53092-3365
US

V. Phone/Fax

Practice location:
  • Phone: 414-302-9196
  • Fax:
Mailing address:
  • Phone: 414-365-3210
  • Fax: 414-365-2937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number14743020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: