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General NPI Number Information
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NPI Number | 1033884721
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Entity Type | Organization
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Legal Business Name | WESTERN MICHIGAN UNIVERSITY
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Dates
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Enumeration Date | 08/13/2021
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Last Update Date | 12/17/2021
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Provider Practice Location Address
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Address Line | 1903 W MICHIGAN AVE
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City | KALAMAZOO
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State | MI
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Zip | 49008-5200
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Country | US
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Telephone | 972-367-4845
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Fax |
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Provider Business Mailing Address
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Address Line | 15305 DALLAS PKWY STE 800
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City | ADDISON
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State | TX
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Zip | 75001-6415
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Country | US
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Telephone | 972-367-4845
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR/AGENT
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Name | MR. MOUZON BASS III
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Credential |
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Telephone | 972-367-4845
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number |
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License Number State |
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