Provider Demographics
NPI:1679596860
Name:ST DOMINIC-JACKSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:ST DOMINIC-JACKSON MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOURY
Authorized Official - Suffix:
Authorized Official - Credentials:CPA, FHFMA
Authorized Official - Phone:601-200-6950
Mailing Address - Street 1:969 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4606
Mailing Address - Country:US
Mailing Address - Phone:601-200-2000
Mailing Address - Fax:600-200-0924
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-2000
Practice Address - Fax:600-200-0924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14-031273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00020034Medicaid
MS25-S048Medicare ID - Type Unspecified