Provider Demographics
NPI:1689997280
Name:CA GROUP LLC
Entity Type:Organization
Organization Name:CA GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE, MBA, MHSA
Authorized Official - Phone:618-257-6301
Mailing Address - Street 1:4500 MEMORIAL DRIVE
Mailing Address - Street 2:MEDICAL AFFAIRS OFFICE
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226
Mailing Address - Country:US
Mailing Address - Phone:618-257-6568
Mailing Address - Fax:618-257-6946
Practice Address - Street 1:4600 MEMORIAL DRIVE
Practice Address - Street 2:STE. W-1
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-233-3066
Practice Address - Fax:618-233-3180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3348Medicare PIN
ILIL3348Medicare Oscar/Certification