Basic Information
| Provider Information | |||||||||
| NPI: | 1093258154 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MSA ALLIANCE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 MEMORIAL DRIVE | ||||||||
| Address2: | MEMORIAL HOSPITAL MEDICAL AFFAIRS CREDENTIALING DEPT | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182574644 | ||||||||
| FaxNumber: | 6182576946 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEMORIAL DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182221020 | ||||||||
| FaxNumber: | 6182221039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2016 | ||||||||
| LastUpdateDate: | 11/22/2016 | ||||||||
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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 MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.