1760939060 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 1760939060 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:
1760939060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
MEMORIAL HOSPITAL MEDICAL AFFAIRS
Provider Second Line Business Mailing Address:
4500 MEMORIAL DRIVE CREDENTIALING DEPARTMENT
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:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1404 CROSS ST
Provider Second Line Business Practice Location Address:
SUITE 2114
Provider Business Practice Location Address City Name:
SHILOH
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62269-2988
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-233-2220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2016

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: 207RP1001X , with the licence number:  036125732 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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