# ST. DOMINIC MEDICAL ASSOCIATES LLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** ST DOMINC JACKSON MEMORIAL HOSPITAL
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1407920549
- **Legal business name:** ST DOMINC JACKSON MEMORIAL HOSPITAL
- **Authorized official:** DANIELLE STUART (CREDENTIALING SPECIALIST)
- **Authorized official phone:** (601) 200-4880

## Contact information

- **Practice address:** 969 LAKELAND DR, JACKSON, MS 39216-4606
- **Practice address phone:** (601) 200-4749
- **Practice address fax:** (601) 200-5929
- **Mailing address:** PO BOX 23666, JACKSON, MS 39225-3666
- **Mailing address phone:** (601) 200-4749
- **Mailing address fax:** (601) 200-5929

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207T00000X | Neurological Surgery Physician | — | NULL | — |
| 207T00000X | Neurological Surgery Physician | — | — | — |
| 207VX0201X | Gynecologic Oncology Physician | — | NULL | — |
| 207VX0201X | Gynecologic Oncology Physician | — | — | — |
| 207Y00000X | Otolaryngology Physician | — | NULL | — |
| 207Y00000X | Otolaryngology Physician | — | — | — |
| 2084N0400X | Neurology Physician | — | NULL | — |
| 2084N0400X | Neurology Physician | — | — | — |
| 2084P0800X | Psychiatry Physician | — | NULL | — |
| 2084P0800X | Psychiatry Physician | — | — | — |
| 2086S0102X | Surgical Critical Care Physician | — | NULL | — |
| 2086S0102X | Surgical Critical Care Physician | — | — | — |
| 208800000X | Urology Physician | — | NULL | — |
| 208800000X | Urology Physician | — | — | — |
| 208G00000X | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician | — | NULL | — |
| 208G00000X | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician | — | — | — |
| 208VP0000X | Pain Medicine Physician | — | NULL | — |
| 208VP0000X | Pain Medicine Physician | — | — | — |

## Other

- **Enumeration date:** 11/20/2006
- **Last updated:** 11/18/2021