Provider Demographics
NPI:1568029205
Name:MUSKINGUM UNIVERSITY
Entity Type:Organization
Organization Name:MUSKINGUM UNIVERSITY
Other - Org Name:MUSKINGUM SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/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 1:15305 DALLAS PKWY STE 800
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-6415
Mailing Address - Country:US
Mailing Address - Phone:972-367-4845
Mailing Address - Fax:
Practice Address - Street 1:163 STORMONT ST
Practice Address - Street 2:
Practice Address - City:NEW CONCORD
Practice Address - State:OH
Practice Address - Zip Code:43762-1118
Practice Address - Country:US
Practice Address - Phone:740-826-8211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-28
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty