Provider Demographics
NPI:1508263179
Name:ST DOMINIC MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:ST DOMINIC MEDICAL ASSOCIATES LLC
Other - Org Name:ST. DOMINIC FAMILY PRACTICE ASSOCIATES-JACKSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING REPRESENTATIVE 2
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:601-200-3131
Mailing Address - Fax:601-200-0710
Practice Address - Street 1:890 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4644
Practice Address - Country:US
Practice Address - Phone:601-200-3131
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:2014-11-26
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR886071363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04838265Medicaid