MEDICARE: SAINT PETER'S UNIVERSITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician

General Provider Information

NPI Number	:	1407336605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAINT PETER'S UNIVERSITY

Provider Business Mailing Address
First Line	:	5050 SPRING VALLEY RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75244-3995
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2641 JOHN F KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-5943
Country	:	US
Telephone Number	:	972-367-4845
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MOUZON BASS III
Credential	:
Telephone Number	:	972-367-4845

Provider Enumeration Date	:	08/16/2018
Last Update Date	:	08/16/2018

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Directions to “SAINT PETER'S UNIVERSITY ” Practice Location

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