MEDICARE: FORT VALLEY STATE 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	207RS0010X	Sports Medicine (Internal Medicine) Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1457737769
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT VALLEY STATE UNIVERSITY

Provider Business Mailing Address
First Line	:	PO BOX 650850
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75265-0850
Country	:	US
Telephone Number	:	800-555-9073
Fax Number	:	972-367-3452

Provider Business Practice Location Address
First Line	:	1005 STATE UNIVERSITY DR
Second Line	:
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-4313
Country	:	US
Telephone Number	:	478-825-6195
Fax Number	:

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

Provider Enumeration Date	:	08/10/2015
Last Update Date	:	08/10/2015

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Directions to “FORT VALLEY STATE UNIVERSITY ” Practice Location

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