MEDICARE: JAMES ALEXANDER DAVIS ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1124890314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES ALEXANDER DAVIS ATC

Provider Business Mailing Address
First Line	:	400 N MORRISON AVE
Second Line	:
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-3428
Country	:	US
Telephone Number	:	618-979-3648
Fax Number	:

Provider Business Practice Location Address
First Line	:	315 E COLLEGE AVE
Second Line	:
City	:	GREENVILLE
State	:	IL
Zip	:	62246-1145
Country	:	US
Telephone Number	:	618-979-3648
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2023
Last Update Date	:	10/23/2023

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