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Organization
MIDDLE GEORGIA STATE UNIVERSITY
Active
Organization
MIDDLE GEORGIA STATE UNIVERSITY
Active
Other names
Middle Georgia State University Sports Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
MOUZON BASS III (AGENT)
(972) 367-4845
Entity
Organization
Contact information
Practice address
1100 2ND ST SE, COCHRAN, GA 31014-1564
(972) 367-4845
(972) 367-3451
Mailing address
5050 SPRING VALLEY RD, DALLAS, TX 75244-3995
(800) 555-9073
(972) 367-3452
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
NULL
207Q00000X
Family Medicine Physician
Primary
—
—
207QS0010X
Sports Medicine (Family Medicine) Physician
—
NULL
207QS0010X
Sports Medicine (Family Medicine) Physician
—
—
Other
Enumeration date
10/19/2015
Last updated
10/19/2015
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