Basic Information
| Provider Information | |||||||||
| NPI: | 1285987578 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST DOMINIC MEDICAL ASSOCIATES LLC | ||||||||
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| OtherOrganizationName: | ST. DOMINIC HOSPITAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23666 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004644 | ||||||||
| FaxNumber: | 6012004645 | ||||||||
| Practice Location | |||||||||
| Address1: | 969 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012005900 | ||||||||
| FaxNumber: | 6012000204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2012 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | STUART | ||||||||
| AuthorizedOfficialFirstName: | DANIELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING REPRESENTATIVE 2 | ||||||||
| AuthorizedOfficialTelephone: | 6012004880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST DOMINIC JACKSON MEMORIAL HOSPITAL | ||||||||
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| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 02055703 | 05 | MS | MEDICAID |