Healthcare Provider Details

I. General information

NPI: 1669742417
Provider Name (Legal Business Name): ST DOMINIC MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR
JACKSON MS
39216-4643
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-987-9007
  • Fax: 601-987-9190
Mailing address:
  • Phone: 601-200-4749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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