Healthcare Provider Details

I. General information

NPI: 1528438116
Provider Name (Legal Business Name): MINNESOTA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 MYERS FIELDHOUSE
MANKATO MN
56001-6171
US

IV. Provider business mailing address

PO BOX 650850
DALLAS TX
75265-0850
US

V. Phone/Fax

Practice location:
  • Phone: 507-389-2099
  • Fax: 972-367-3452
Mailing address:
  • Phone: 800-555-9073
  • Fax: 972-367-3451

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: OFFICE MANAGER
Credential:
Phone: 972-367-4845