Organization
NORTHEASTERN STATE UNIVERSITY
Active
Other names
Northeastern 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
603 N GRAND AVE, TAHLEQUAH, OK 74464-2302
(918) 444-3921
(972) 367-3451
Mailing address
PO BOX 650850, DEPT 1011, DALLAS, TX 75265-0850
(800) 555-9073
(972) 367-3452
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
—
—
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
—
—
Other
Enumeration date
11/12/2015
Last updated
11/12/2015
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