Provider Demographics
NPI:1902374085
Name:ST. DOMINIC MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:ST. DOMINIC MEDICAL ASSOCIATES LLC
Other - Org Name:ST. DOMINIC GASTROENTEROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
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 1:971 LAKELAND DR STE 250
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4620
Mailing Address - Country:US
Mailing Address - Phone:601-200-5550
Mailing Address - Fax:601-200-4887
Practice Address - Street 1:971 LAKELAND DR STE 250
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4620
Practice Address - Country:US
Practice Address - Phone:601-200-5550
Practice Address - Fax:601-200-4887
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. DOMINIC-JACKSON MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-07
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty