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General NPI Number Information
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NPI Number | 1598284408
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Entity Type | Organization
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Legal Business Name | ALBANY STATE UNIVERSITY
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Dates
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Enumeration Date | 09/12/2017
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Last Update Date | 09/12/2017
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Provider Practice Location Address
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Address Line | 504 COLLEGE DR
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City | ALBANY
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State | GA
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Zip | 31705-2717
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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 | 5050 SPRING VALLEY RD
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City | DALLAS
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State | TX
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Zip | 75244-3995
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | AGENT
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Name | 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 | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 008291
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License Number State | GA
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