Healthcare Provider Details

I. General information

NPI: 1104362292
Provider Name (Legal Business Name): ST. DOMINIC HOSPITAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 09/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4644
  • Fax: 601-200-4645
Mailing address:
  • Phone: 601-200-4749
  • Fax: 601-200-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER SINCLAIR
Title or Position: PRESIDENT OF SDMA
Credential:
Phone: 601-200-6955