Healthcare Provider Details

I. General information

NPI: 1093032849
Provider Name (Legal Business Name): ST DOMINIC MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR ST THOMAS HALL
JACKSON MS
39216-4606
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-3110
  • Fax: 601-200-3109
Mailing address:
  • Phone: 601-200-4749
  • Fax:

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: CHIEF FINANCIAL OFFICER
Credential:
Phone: 601-200-2000