Healthcare Provider Details

I. General information

NPI: 1760939060
Provider Name (Legal Business Name): MSA ALLIANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 CROSS ST SUITE 2114
SHILOH IL
62269-2988
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 618-233-2220
  • Fax:
Mailing address:
  • Phone: 618-257-4644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036125732
License Number StateIL

VIII. Authorized Official

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