Provider Demographics
NPI:1003295213
Name:MSA ALLIANCE, LLC DBA-SOUTHERN ILLINOIS VASCULAR AND VEIN SURGERY
Entity Type:Organization
Organization Name:MSA ALLIANCE, LLC DBA-SOUTHERN ILLINOIS VASCULAR AND VEIN SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-257-4644
Mailing Address - Street 1:4500 MEMORIAL DRIVE CREDENTIALING DEPT
Mailing Address - Street 2:MEMORIAL HOSPITAL MEDICAL AFFAIRS
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226
Mailing Address - Country:US
Mailing Address - Phone:618-257-4644
Mailing Address - Fax:
Practice Address - Street 1:6810 STATE ROUTE 162
Practice Address - Street 2:SUITE 100
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062
Practice Address - Country:US
Practice Address - Phone:618-334-2425
Practice Address - Fax:618-222-1039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty