Provider Demographics
NPI:1255303517
Name:ST DOMINIC AMBULATORY SURGERY CENTER L L C
Entity Type:Organization
Organization Name:ST DOMINIC AMBULATORY SURGERY CENTER L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:YELVERTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-984-8800
Mailing Address - Street 1:970 LAKELAND DR.
Mailing Address - Street 2:SUITE 15
Mailing Address - City:JAKCSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-984-8800
Mailing Address - Fax:601-321-8670
Practice Address - Street 1:970 LAKELAND DR
Practice Address - Street 2:SUITE 15
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4601
Practice Address - Country:US
Practice Address - Phone:601-984-8800
Practice Address - Fax:601-321-8670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS011261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0770362Medicaid
MS0770362Medicaid