1821307554 NPI number — MSA ALLIANCE, LLC

Table of content: (NPI 1821307554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821307554 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:
1821307554
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 MEMORIAL DR
Provider Second Line Business Mailing Address:
MEDICAL AFFAIRS CREDENTIALING DEPARTMENT
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62226-5360
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:
4700 MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
STE. 230
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-257-5902
Provider Business Practice Location Address Fax Number:
618-257-6671
Provider Enumeration Date:
09/29/2010

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: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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