Healthcare Provider Details

I. General information

NPI: 1326646845
Provider Name (Legal Business Name): ST. DOMINIC MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 HIGHLAND WAY STE 208
MADISON MS
39110-6929
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-3376
  • Fax: 601-200-4475
Mailing address:
  • Phone: 601-200-3376
  • Fax: 601-200-4475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

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