Healthcare Provider Details

I. General information

NPI: 1790409837
Provider Name (Legal Business Name): PHILLIP MAZUR SW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 BRODHEAD RD
BETHLEHEM PA
18017-8938
US

IV. Provider business mailing address

801 OSTRUM ST ENROLLMENT DEPT
BETHLEHEM PA
18015-1000
US

V. Phone/Fax

Practice location:
  • Phone: 484-822-5700
  • Fax: 484-822-5796
Mailing address:
  • Phone: 484-526-4999
  • Fax: 833-213-6428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW139393
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: