1093258154 NPI number — MSA ALLIANCE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093258154 NPI number — MSA ALLIANCE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MSA ALLIANCE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093258154
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 MEMORIAL DRIVE
Provider Second Line Business Mailing Address:
MEMORIAL HOSPITAL MEDICAL AFFAIRS CREDENTIALING DEPT
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-257-4644
Provider Business Mailing Address Fax Number:
618-257-6946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 MEMORIAL DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
ALTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62002-6723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-222-1020
Provider Business Practice Location Address Fax Number:
618-222-1039
Provider Enumeration Date:
11/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
B
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
618-257-4644

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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