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MIDDLE GEORGIA STATE UNIVERSITY SPORTS MEDICINE
NPI 1629449400
Family Medicine in Cochran, GA

Active since October 19, 2015CLIA 11D2132677 · Waiver
1100 2ND ST SE, COCHRAN, GA 31014(972) 367-4845(972) 367-3451 Get Directions Write a Review

NPPES record last updated: October 19, 2015. Verified against the NPPES registry weekly; last sync: August 09, 2026.

About Middle Georgia State University Sports Medicine NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

MIDDLE GEORGIA STATE UNIVERSITY SPORTS MEDICINE (NPI 1629449400) is a healthcare organization registered as a family medicine in Cochran, Georgia and active in the NPI registry since October 2015. The organization holds a CLIA Waiver certificate valid through June 26, 2027 and lists Mouzon Bass, Agent, as its authorized official.

NPPES Registry Identity

NPI1629449400
Entity TypeOrganization
Primary Taxonomy207Q00000X
Legal Business NameMIDDLE GEORGIA STATE UNIVERSITY
Location Address1100 2ND ST SECochran, GA 31014-1564
Mailing Address5050 Spring Valley RdDallas, TX 75244-3995 · (800) 555-9073 · Fax (972) 367-3452
Phone(972) 367-4845
Fax(972) 367-3451
Organization SubpartNo
Authorized OfficialMouzon BassAgent · (972) 367-4845
Enumeration DateOctober 19, 2015
✔ NPI 1629449400 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses 2

★ Primary SpecialtyFamily MedicineAllopathic & Osteopathic Physicians
Taxonomy Code207Q00000X
Definition
Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity.
Also ListedFamily Medicine · Sports MedicineTaxonomy 207QS0010X
1100 2ND ST SE, Cochran, GA 31014
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Other Names 1

Doing Business AsMiddle Georgia State University Sports Medicine

Group Practice 1

Group TaxonomyThis provider is a business group of one or more individual practitioners, who practice with different areas of specialization.193200000X MULTI-SPECIALTY GROUP

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 11D2132677

Middle Georgia State University · Cochran, GA
Active · expires Jun 26, 2027
CLIA Number11D2132677
Laboratory TypeSchool/Student Health Service
Certificate Effective DateJune 27, 2025
Certificate Expiration DateJune 26, 2027
Laboratory DirectorDaniela L. Torries
Laboratory Phone(478) 271-5401
Laboratory LocationMiddle Georgia State University1100 2nd Street, SE, (health Clinic), Cochran, GA 31014
CLIA data matches this NPI record on: Address Name
This certificate is issued to a laboratory to perform only waived tests.

Other Providers at the Same Location NPPES 2

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

MR. THOMAS CHARLES SIMMONS L.A.T., A.T.C.
Specialist/Technologist (Athletic Trainer)
1100 2ND ST SE, MIDDLE GEORGIA COLLEGE
COCHRAN, GA 31014
Bleckley County (478) 934-3117
GAYLA FISHER MCLEOD ATC/LAT
Specialist/Technologist (Athletic Trainer)
1100 2ND ST SE
COCHRAN, GA 31014
Bleckley County (478) 934-3423

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Middle Georgia State University's NPI number?

The NPI number for Middle Georgia State University is 1629449400. It was assigned to this organization in the NPPES registry on October 19, 2015. The provider is doing business as Middle Georgia State University Sports Medicine.

Where is Middle Georgia State University located?

Middle Georgia State University is located at 1100 2nd St SE, Cochran, GA 31014. The listed phone number is (972) 367-4845.

What is Middle Georgia State University's specialty?

The primary specialty registered for this NPI is Family Medicine with taxonomy code 207Q00000X.

Does Middle Georgia State University hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 11D2132677) is associated with this NPI, valid through June 26, 2027. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Middle Georgia State University was last updated on October 19, 2015. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 10 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.