NPIMap

Organization Active NPI

Edgewood College, Inc

Doing business as Edgewood College Sports Medicine

  • Family Medicine Physician
  • Madison, WI
National Provider Identifier
1740739622
Registry record updated Oct 3, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
64261-21 Issued in WI
Legal business name
EDGEWOOD COLLEGE, INC
Doing business as
Edgewood College Sports Medicine
Practice address
1000 Edgewood College Dr
Madison, WI 53711-1997
Phone
(608) 663-4861
NPI assigned
Oct 3, 2016
Last updated
Oct 3, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 3, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mouzon Bass
Title
Agent
Phone
(972) 367-4845

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X 64261-21 WI Primary

Addresses

Primary practice location

1000 Edgewood College Dr
Madison, WI 53711-1997

Mailing address

5050 Spring Valley Rd.
Dallas, TX 75244-3909

Other names 1

  • Edgewood College Sports Medicine Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Edgewood College Health Services4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1475452800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1475452800000",
    "number": "1740739622",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5050 SPRING VALLEY RD.",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752443909"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1000 EDGEWOOD COLLEGE DR",
            "city": "MADISON",
            "state": "WI",
            "postal_code": "537111997",
            "telephone_number": "608-663-4861"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EDGEWOOD COLLEGE, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-10-03",
        "last_updated": "2016-10-03",
        "status": "A",
        "authorized_official_last_name": "BASS",
        "authorized_official_first_name": "MOUZON",
        "authorized_official_title_or_position": "AGENT",
        "authorized_official_telephone_number": "972-367-4845"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "64261-21",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Edgewood College Sports Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Madison, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 3, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.