Healthcare Provider Details

I. General information

NPI: 1396172201
Provider Name (Legal Business Name): MSA ALLIANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2013
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 ADMIRAL WEINEL BLVD
COLUMBIA IL
62236-1992
US

IV. Provider business mailing address

4500 MEMORIAL DRIVE MEMORIAL HOSPITAL MEDICAL AFFAIRS CREDENTIALING DEPT
BELLEVILLE IL
62226
US

V. Phone/Fax

Practice location:
  • Phone: 618-281-7373
  • Fax: 618-281-6463
Mailing address:
  • Phone: 618-257-4644
  • Fax: 618-257-6946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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