Provider Demographics
NPI:1194198192
Name:NORTHEASTERN STATE UNIVERSITY
Entity Type:Organization
Organization Name:NORTHEASTERN STATE UNIVERSITY
Other - Org Name:NORTHEASTERN STATE UNIVERSITY SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:MOUZON
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:972-367-4845
Mailing Address - Street 1:PO BOX 650850
Mailing Address - Street 2:DEPT 1011
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0850
Mailing Address - Country:US
Mailing Address - Phone:800-555-9073
Mailing Address - Fax:972-367-3452
Practice Address - Street 1:603 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2302
Practice Address - Country:US
Practice Address - Phone:918-444-3921
Practice Address - Fax:972-367-3451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty