Healthcare Provider Details

I. General information

NPI: 1356732481
Provider Name (Legal Business Name): ST DOMINIC MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR SUITE
JACKSON MS
39216-4643
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4749
  • Fax: 601-200-5929
Mailing address:
  • Phone: 601-200-4749
  • Fax: 601-200-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number StateMS

VIII. Authorized Official

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