# MINNESOTA STATE UNIVERSITY

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- **Entity:** Organization
- **Status:** Active
- **Other names:** MSU Sports Medicine
- **Organization subpart:** No

## Provider details

- **NPI number:** 1528438116
- **Authorized official:** MOUZON BASS III (OFFICE MANAGER)
- **Authorized official phone:** (972) 367-4845

## Contact information

- **Practice address:** 135 MYERS FIELDHOUSE, MANKATO, MN 56001-6171
- **Practice address phone:** (507) 389-2099
- **Practice address fax:** (972) 367-3452
- **Mailing address:** PO BOX 650850, DALLAS, TX 75265-0850
- **Mailing address phone:** (800) 555-9073
- **Mailing address fax:** (972) 367-3451

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207X00000X | Orthopaedic Surgery Physician | — | NULL | Yes |
| 207X00000X | Orthopaedic Surgery Physician | — | — | Yes |
| 207XX0005X | Sports Medicine (Orthopaedic Surgery) Physician | — | NULL | — |
| 207XX0005X | Sports Medicine (Orthopaedic Surgery) Physician | — | — | — |

## Other

- **Enumeration date:** 09/25/2015
- **Last updated:** 09/25/2015