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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