Provider Demographics
NPI:1245393255
Name:ST. DOMINIC MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:ST. DOMINIC MEDICAL ASSOCIATES LLC
Other - Org Name:ST DOMINIC FAMILY PRACTICE ASSOCIATES MADISON
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 1:106 HIGHLAND WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6929
Practice Address - Country:US
Practice Address - Phone:601-200-4750
Practice Address - Fax:601-200-4740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00975207Medicaid
MS00975207Medicaid