Healthcare Provider Details

I. General information

NPI: 1285987578
Provider Name (Legal Business Name): ST DOMINIC MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-5900
  • Fax: 601-200-0204
Mailing address:
  • Phone: 601-200-4644
  • Fax: 601-200-4645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DANIELLE STUART
Title or Position: CREDENTIALING REPRESENTATIVE 2
Credential:
Phone: 601-200-4880