Healthcare Provider Details

I. General information

NPI: 1245393255
Provider Name (Legal Business Name): ST. DOMINIC MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 HIGHLAND WAY SUITE 103
MADISON MS
39110-6929
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4750
  • Fax: 601-200-4740
Mailing address:
  • Phone: 601-200-4749
  • Fax: 601-200-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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