Provider Demographics
NPI:1689063067
Name:ST DOMINIC MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:ST DOMINIC MEDICAL ASSOCIATES LLC
Other - Org Name:ST DOMINIC UROLOGY
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 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 360
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-200-4370
Practice Address - Fax:601-200-4375
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST DOMINIC JACKSON MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-22
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11495208800000X
MS13524208800000X
MS09524208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06782543Medicaid
MS302G700675Medicare PIN