Healthcare Provider Details

I. General information

NPI: 1760819676
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

4017 ILLINOIS ROUTE 159, SUITE 101
SMITHTON IL
62285
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: 618-257-2875
  • Fax: 618-257-2895
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