Healthcare Provider Details

I. General information

NPI: 1356713572
Provider Name (Legal Business Name): WESTERN NEW ENGLAND UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 10/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 WILBRAHAM RD
SPRINGFIELD MA
01119-2612
US

IV. Provider business mailing address

PO BOX 650850 DEPT 1011
DALLAS TX
75265-0850
US

V. Phone/Fax

Practice location:
  • Phone: 413-782-1202
  • Fax: 972-367-3451
Mailing address:
  • Phone: 972-367-4845
  • Fax: 972-367-3452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MOUZON BASS III
Title or Position: AGENT
Credential:
Phone: 972-367-4845