Provider Demographics
NPI:1821544479
Name:PITTSBURG STATE UNIVERSITY
Entity Type:Organization
Organization Name:PITTSBURG STATE UNIVERSITY
Other - Org Name:PITTSBURG 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 1:5050 SPRING VALLEY RD.
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-3909
Mailing Address - Country:US
Mailing Address - Phone:972-367-4845
Mailing Address - Fax:
Practice Address - Street 1:1701 S BROADWAY ST
Practice Address - Street 2:110 RUSS HALL
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-5856
Practice Address - Country:US
Practice Address - Phone:620-231-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-28648207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty