Basic Information
| Provider Information | |||||||||
| NPI: | 1871511196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HLAVACEK | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HLAVACEK | ||||||||
| OtherFirstName: | JAMES | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2001 BUTTERFIELD RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307252700 | ||||||||
| FaxNumber: | 6307252783 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MID AMERICA PLZ | ||||||||
| Address2: | SUIE 720 | ||||||||
| City: | OAKBROOK TERRACE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601814451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305710055 | ||||||||
| FaxNumber: | 6305711335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 06/22/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 036-060125 | IL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208D00000X | 036060125 | IL | Y | Allopathic & Osteopathic Physicians | General Practice | 208600000X | 036060125 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 036060125 | IL | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 789510 | 01 | IL | GROUP MEDICARE PTAN | OTHER | 789511 | 01 | IL | GROUP MEDICARE PTAN | OTHER | 036060125 | 05 | IL | MEDICAID | 36060125 | 01 | IL | LICENSE | OTHER | P00930 | 01 | INDIVIDUAL MEDICARE # | OTHER |