Provider Demographics
NPI:1083032171
Name:ST DOMINIC MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:ST DOMINIC MEDICAL ASSOCIATES LLC
Other - Org Name:ST DOMINIC RALEIGH FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:STUART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-200-4880
Mailing Address - Street 1:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:342 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:MS
Practice Address - Zip Code:39153-6012
Practice Address - Country:US
Practice Address - Phone:601-200-6809
Practice Address - Fax:601-200-5929
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST DOMINIC JACKSON MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-04
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16442207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty