NPIMap

Organization Active NPI

Southeast Missouri State University

  • Sports Medicine (Physical Medicine & Rehabilitation) Physician
  • Cape Girardeau, MO
National Provider Identifier
1871003301
Registry record updated Dec 17, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Sports Medicine (Physical Medicine & Rehabilitation) PhysicianTaxonomy code 2081S0010X
License
2007008844 Issued in MO
Legal business name
SOUTHEAST MISSOURI STATE UNIVERSITY
Doing business as
SEMO State Sports Medicine
Practice address
1 University PLZ # Ms 0200
Cape Girardeau, MO 63701-4710
Phone
(972) 367-4845
NPI assigned
Oct 11, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 17, 2021

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Sports Medicine (Physical Medicine & Rehabilitation) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2081S0010X 2007008844 MO Primary

Addresses

Primary practice location

1 University PLZ # Ms 0200
Cape Girardeau, MO 63701-4710

Mailing address

15305 Dallas Pkwy Ste 800
Addison, TX 75001-6415
Phone (972) 367-4845

Other names 1

  • SEMO State Sports Medicine Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Horizons Enrichment Center4 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.

Locations

1 University Plz
#200
Cape Girardeau, MO 63701

NPI Registry JSON

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

{
    "created_epoch": "1507680000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1639699200000",
    "number": "1871003301",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "15305 DALLAS PKWY STE 800",
            "city": "ADDISON",
            "state": "TX",
            "postal_code": "750016415",
            "telephone_number": "972-367-4845"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 UNIVERSITY PLZ # MS 0200",
            "city": "CAPE GIRARDEAU",
            "state": "MO",
            "postal_code": "637014710",
            "telephone_number": "972-367-4845"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST MISSOURI STATE UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-10-11",
        "last_updated": "2021-12-17",
        "certification_date": "2021-12-17",
        "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",
        "authorized_official_name_suffix": "III"
    },
    "taxonomies": [
        {
            "code": "2081S0010X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Medicine & Rehabilitation, Sports Medicine",
            "state": "MO",
            "license": "2007008844",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SEMO State Sports Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cape Girardeau, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 17, 2021; 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.