Healthcare Provider Details

I. General information

NPI: 1821472861
Provider Name (Legal Business Name): OAKLAND UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2015
Last Update Date: 07/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 ATHLETICS CTR
ROCHESTER MI
48309
US

IV. Provider business mailing address

PO BOX 650850
DALLAS TX
75265-0850
US

V. Phone/Fax

Practice location:
  • Phone: 248-370-3787
  • Fax: 972-367-3452
Mailing address:
  • Phone: 800-555-9073
  • Fax: 972-367-3452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MOUZON BASS III
Title or Position: AGENT
Credential:
Phone: 18005559073