Healthcare Provider Details

I. General information

NPI: 1033510284
Provider Name (Legal Business Name): MSA ALLIANCE, LLC DBA-SOUTHERN ILLINOIS VASCULAR AND VEIN SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DR SUITE120
BELLEVILLE IL
62226-5368
US

IV. Provider business mailing address

4500 MEMORIAL DRIVE MEMORIAL HOSPITAL MEDICAL AFFAIRS
BELLEVILLE IL
62226
US

V. Phone/Fax

Practice location:
  • Phone: 618-222-1020
  • Fax:
Mailing address:
  • Phone: 618-257-4644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

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