Healthcare Provider Details

I. General information

NPI: 1922321546
Provider Name (Legal Business Name): MSA ALLIANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 01/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 MEMORIAL DRIVE STE. 280
BELLEVILLE IL
62226
US

IV. Provider business mailing address

4500 MEMORIAL DRIVE MEDICAL AFFAIRS OFFICE
BELLEVILLE IL
62226
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-3109
  • Fax: 618-233-5696
Mailing address:
  • Phone: 618-257-6568
  • Fax: 618-257-6946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES B. DAVIS
Title or Position: EXECUTIVE DIRECTOR
Credential: FACHE, MBA, MHSA
Phone: 618-257-6301