Healthcare Provider Details

I. General information

NPI: 1083032171
Provider Name (Legal Business Name): ST DOMINIC MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 MAGNOLIA DR
RALEIGH MS
39153-6012
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-6809
  • Fax: 601-200-5929
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 Number16442
License Number StateMS

VIII. Authorized Official

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