Basic Information
| Provider Information | |||||||||
| NPI: | 1821490723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE UNIVERSITY OF SOUTHERN MISSISSIPPI | ||||||||
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| OtherOrganizationName: | USM SPORTS MEDICINE AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 SPRING VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752443995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005559073 | ||||||||
| FaxNumber: | 9723673452 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 COLLEGE DR | ||||||||
| Address2: | 5017 | ||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394060002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012665401 | ||||||||
| FaxNumber: | 6012666821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2014 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | MCCALL | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEAD ATHLETICS TRAINER | ||||||||
| AuthorizedOfficialTelephone: | 6012665401 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.