Healthcare Provider Details

I. General information

NPI: 1114231586
Provider Name (Legal Business Name): MSA ALLIANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DR STE 120
BELLEVILLE IL
62226-5368
US

IV. Provider business mailing address

4500 MEMORIAL DR MEDICAL AFFAIRS CREDENTIALING DEPARTMENT
BELLEVILLE IL
62226-5360
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-2220
  • Fax: 618-233-2555
Mailing address:
  • Phone: 618-257-4644
  • Fax: 618-222-9337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES B. DAVIS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 618-257-4644