Healthcare Provider Details

I. General information

NPI: 1639692973
Provider Name (Legal Business Name): OA ASSOCIATED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 CROSS ST STE 110
SHILOH IL
62269-2988
US

IV. Provider business mailing address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-9884
  • Fax: 618-235-9020
Mailing address:
  • Phone: 618-257-4644
  • Fax: 618-257-6946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State

VIII. Authorized Official

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