Basic Information
| Provider Information | |||||||||
| NPI: | 1063936235 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILLIGAN COLLEGE | ||||||||
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| OtherOrganizationName: | MILLIGAN COLLEGE SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 SPRING VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752443995 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | ONE BLOWERS BLVD. | ||||||||
| Address2: | ATHLETICS | ||||||||
| City: | MILLIGAN COLLEGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723674845 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2017 | ||||||||
| LastUpdateDate: | 07/31/2017 | ||||||||
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| AuthorizedOfficialLastName: | BASS | ||||||||
| AuthorizedOfficialFirstName: | MOUZON | ||||||||
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| AuthorizedOfficialTitleorPosition: | AGENT | ||||||||
| AuthorizedOfficialTelephone: | 9723674845 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 000024265 | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.