Basic Information
| Provider Information | |||||||||
| NPI: | 1760939060 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MSA ALLIANCE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | MEMORIAL HOSPITAL MEDICAL AFFAIRS | ||||||||
| Address2: | 4500 MEMORIAL DRIVE CREDENTIALING DEPARTMENT | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182574644 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1404 CROSS ST | ||||||||
| Address2: | SUITE 2114 | ||||||||
| City: | SHILOH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622692988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182332220 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2016 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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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 | 207RP1001X | 036125732 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.