Healthcare Provider Details

I. General information

NPI: 1760542567
Provider Name (Legal Business Name): NORTHWEST MISSOURI STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 UNIVERSITY DRIVE
MARYVILLE MO
64468
US

IV. Provider business mailing address

800 UNIVERSITY DRIVE
MARYVILLE MO
64468
US

V. Phone/Fax

Practice location:
  • Phone: 660-562-1348
  • Fax: 660-562-1585
Mailing address:
  • Phone: 660-562-1348
  • Fax: 660-562-1585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SUSAN WATSON
Title or Position: MEDICAL DIRECTOR / PHYSICIAN
Credential: MD
Phone: 660-562-1348