Basic Information
| Provider Information | |||||||||
| NPI: | 1649279951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZUR | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | ALEXANDER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 DUNNYVEG RD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND HILL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313245165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127273808 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5 EXECUTIVE CIR | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314063345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126911533 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 037864 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 415967345F | 05 | GA | MEDICAID | 415967345A | 05 | GA | MEDICAID | 415967345D | 05 | GA | MEDICAID | 415967345E | 05 | GA | MEDICAID | 415967345G | 05 | GA | MEDICAID | 10058807 | 01 | GA | AMERIGROUP | OTHER | G37864 | 05 | SC | MEDICAID | 415967345C | 05 | GA | MEDICAID |