Healthcare Provider Details

I. General information

NPI: 1316251788
Provider Name (Legal Business Name): MSA ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

4600 MEMORIAL DR STE 325
BELLEVILLE IL
62226-5368
US

IV. Provider business mailing address

PO BOX 24035
BELLEVILLE IL
62223-9035
US

V. Phone/Fax

Practice location:
  • Phone: 618-236-6501
  • Fax: 618-236-6551
Mailing address:
  • Phone: 618-222-9999
  • Fax: 618-222-9337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES B DAVIS
Title or Position: VP MEDICAL STAFF SERVICES
Credential: FACHE, MBA, MHSA
Phone: 618-257-6302