Provider Demographics
NPI:1760542567
Name:NORTHWEST MISSOURI STATE UNIVERSITY
Entity type:Organization
Organization Name:NORTHWEST MISSOURI STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR / PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:660-562-1348
Mailing Address - Street 1:800 UNIVERSITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468
Mailing Address - Country:US
Mailing Address - Phone:660-562-1348
Mailing Address - Fax:660-562-1585
Practice Address - Street 1:800 UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468
Practice Address - Country:US
Practice Address - Phone:660-562-1348
Practice Address - Fax:660-562-1585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent HealthGroup - Single Specialty