Provider Demographics
NPI:1225310204
Name:NORTHWEST MISSOURI STATE UNIVERSITY
Entity Type:Organization
Organization Name:NORTHWEST MISSOURI STATE UNIVERSITY
Other - Org Name:NORTHWEST MISSOURI STATE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEAD ATHLETIC TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNELLA
Authorized Official - Suffix:
Authorized Official - Credentials:LAT
Authorized Official - Phone:660-562-1313
Mailing Address - Street 1:800 UNIVERSITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468
Mailing Address - Country:US
Mailing Address - Phone:660-562-1313
Mailing Address - Fax:
Practice Address - Street 1:800 UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468
Practice Address - Country:US
Practice Address - Phone:660-562-1313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-15
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty