=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407158033
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZIEMOWIT MAZUR PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2010
-----------------------------------------------------
Last Update Date | 12/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 CENTER DRIVE
-----------------------------------------------------
City | VERNON HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-527-5329
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 KNOLLWOOD DR
-----------------------------------------------------
City | FLOSSMOOR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60422-1928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-527-5329
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 385.002623
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------