Basic Information
Provider Information | |||||||||
NPI: | 1346510559 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST DOMINIC MEDICAL ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST DOMINIC'S GYNECOLOGIC ONCOLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 23666 | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392253666 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6012004749 | ||||||||
FaxNumber: | 6012005929 | ||||||||
Practice Location | |||||||||
Address1: | 971 LAKELAND DR | ||||||||
Address2: | SUITE 750 | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392164643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6012004970 | ||||||||
FaxNumber: | 6012005943 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/04/2012 | ||||||||
LastUpdateDate: | 03/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STUART | ||||||||
AuthorizedOfficialFirstName: | DANIELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 6012004880 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ST DOMINIC JACKSON MEMORIAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
ID | Type | State | Issuer | Description | 01652268 | 05 | MS |   | MEDICAID |