Healthcare Provider Details

I. General information

NPI: 1508179722
Provider Name (Legal Business Name): MSA ALLIANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DR STE 440
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: 618-628-7560
  • Fax: 618-628-7667
Mailing address:
  • Phone: 618-257-4644
  • Fax: 618-257-6946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number036115955
License Number StateIL

VIII. Authorized Official

Name: LISA K. MCDONALD
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 618-257-4644