Basic Information
| Provider Information | |||||||||
| NPI: | 1174757017 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST DOMINIC MEDICAL ASSOCIATES LLC | ||||||||
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| OtherOrganizationName: | EAR NOSE AND THROAT SURGICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23666 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004749 | ||||||||
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| Practice Location | |||||||||
| Address1: | 970 LAKELAND DR | ||||||||
| Address2: | SUITE 40 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004850 | ||||||||
| FaxNumber: | 6012004838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2009 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | SINCLAIR | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6012002000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST DOMINIC JACKSON MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.