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General NPI Number Information
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NPI Number | 1326646845
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Entity Type | Organization
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Legal Business Name | ST. DOMINIC MEDICAL ASSOCIATES, LLC
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Dates
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Enumeration Date | 10/16/2020
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Last Update Date | 05/26/2021
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Provider Practice Location Address
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Address Line | 106 HIGHLAND WAY STE 208
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City | MADISON
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State | MS
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Zip | 39110-6929
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Country | US
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Telephone | 601-200-3376
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Fax | 601-200-4475
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Provider Business Mailing Address
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Address Line | PO BOX 23666
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City | JACKSON
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State | MS
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Zip | 39225-3666
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Country | US
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Telephone | 601-200-3376
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Fax | 601-200-4475
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | DANIELLE STUART
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Credential |
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Telephone | 601-200-4880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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