Provider Demographics
NPI:1316361686
Name:ST DOMINIC MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:ST DOMINIC MEDICAL ASSOCIATES LLC
Other - Org Name:ST DOMINIC SURGICAL ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF SDMA
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SINCLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-200-6955
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:STE 200
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6929
Practice Address - Country:US
Practice Address - Phone:601-200-7465
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:2014-02-07
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14863207VX0201X
MS147862086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty