Healthcare Provider Details

I. General information

NPI: 1639219595
Provider Name (Legal Business Name): ST DOMINIC MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 CLINTON PARKWAY SUITE B
CLINTON MS
39056-0000
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4800
  • Fax: 601-924-0473
Mailing address:
  • Phone: 601-200-4800
  • Fax: 601-924-0473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JENNIFER SINCLAIR
Title or Position: PRESIDENT ST DOMINIC MEDICAL ASSOCI
Credential:
Phone: 601-200-2000