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Organization
SOUTHEAST MISSOURI STATE UNIVERSITY
Active
Organization
SOUTHEAST MISSOURI STATE UNIVERSITY
Active
Other names
SEMO State Sports Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
MOUZON BASS III (AGENT)
(972) 367-4845
Entity
Organization
Contact information
Practice address
1 UNIVERSITY PLZ # MS 0200, CAPE GIRARDEAU, MO 63701-4710
(972) 367-4845
Mailing address
15305 DALLAS PKWY STE 800, ADDISON, TX 75001-6415
(972) 367-4845
Taxonomy
Speciality
Code
Description
License number
State
2081S0010X
Sports Medicine (Physical Medicine & Rehabilitation) Physician
Primary
2007008844
MO
Other
Enumeration date
10/11/2017
Last updated
12/17/2021
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