Basic Information
| Provider Information | |||||||||
| NPI: | 1003295213 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MSA ALLIANCE, LLC DBA-SOUTHERN ILLINOIS VASCULAR AND VEIN SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 MEMORIAL DRIVE CREDENTIALING DEPT | ||||||||
| Address2: | MEMORIAL HOSPITAL MEDICAL AFFAIRS | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182574644 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6810 STATE ROUTE 162 | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183342425 | ||||||||
| FaxNumber: | 6182221039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2015 | ||||||||
| LastUpdateDate: | 05/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6182574644 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.