Healthcare Provider Details

I. General information

NPI: 1386871861
Provider Name (Legal Business Name): ST. DOMINIC MEDICAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 06/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

498 HIGHWAY 80 E
CLINTON MS
39056-4720
US

IV. Provider business mailing address

498 HIGHWAY 80 E
CLINTON MS
39056-4720
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-2000
  • Fax:
Mailing address:
  • Phone: 601-200-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateMS

VIII. Authorized Official

Name: JENNIFER SINCLAIR
Title or Position: VICE PRESIDENT OF FINANCE
Credential:
Phone: 601-200-2000