Provider Demographics
NPI:1639219595
Name:ST DOMINIC MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:ST DOMINIC MEDICAL ASSOCIATES, LLC
Other - Org Name:FAMILY PRACTICE ASSOCIATES CLINTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT ST DOMINIC MEDICAL ASSOCI
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:601-200-2000
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:601-200-4800
Mailing Address - Fax:601-924-0473
Practice Address - Street 1:728 CLINTON PARKWAY
Practice Address - Street 2:SUITE B
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-0000
Practice Address - Country:US
Practice Address - Phone:601-200-4800
Practice Address - Fax:601-924-0473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03349Medicare ID - Type UnspecifiedMEDICARE