1508263179 NPI number — ST DOMINIC MEDICAL ASSOCIATES LLC

Table of content: (NPI 1508263179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508263179 NPI number — ST DOMINIC MEDICAL ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST DOMINIC MEDICAL ASSOCIATES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ST. DOMINIC FAMILY PRACTICE ASSOCIATES-JACKSON
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508263179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23666
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39225-3666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-200-3131
Provider Business Mailing Address Fax Number:
601-200-0710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
890 LAKELAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216-4644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-200-3131
Provider Business Practice Location Address Fax Number:
601-200-5929
Provider Enumeration Date:
11/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
STUART
Authorized Official First Name:
DANIELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING REPRESENTATIVE 2
Authorized Official Telephone Number:
601-200-4880

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R886071 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04838265 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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