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Organization Active NPI

St Dominic Medical Associates LLC

Doing business as St Dominic Raleigh Family Practice

  • Family Medicine Physician
  • Raleigh, MS
National Provider Identifier
1083032171
Registry record updated Jul 2, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
16442 Issued in MS
Legal business name
ST DOMINIC MEDICAL ASSOCIATES LLC
Doing business as
St Dominic Raleigh Family Practice
Practice address
342 Magnolia Dr
Raleigh, MS 39153-6012
Phone
(601) 200-6809
Fax
(601) 200-5929
NPI assigned
Apr 4, 2014
Last updated
Jul 2, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
ST DOMINIC JACKSON MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 2, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Danielle Stuart
Title
Credentialing Specialist
Phone
(601) 200-4880

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X 16442 MS Primary

Addresses

Primary practice location

342 Magnolia Dr
Raleigh, MS 39153-6012

Mailing address

PO Box 23666
Jackson, MS 39225-3666
Phone (601) 200-4749

Other practice location 1

360 Simpson Highway 149 Ste 370
Magee, MS 39111-3843
Phone (601) 849-1530

Other names 1

  • St Dominic Raleigh Family Practice Doing business as

National Provider Directory

National Provider Directory
Tax ID family
St Dominic Medical Associates LLC28 organizations share this tax ID, including this one
Part of
Chemical Dependency Uni

Other organizations with this tax ID 27

Organizations that report the same tax identification number in the National Provider Directory.

View all 27

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1396569600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1562025600000",
    "number": "1083032171",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 23666",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392253666",
            "telephone_number": "601-200-4749",
            "fax_number": "601-200-5929"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "342 MAGNOLIA DR",
            "city": "RALEIGH",
            "state": "MS",
            "postal_code": "391536012",
            "telephone_number": "601-200-6809",
            "fax_number": "601-200-5929"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "360 Simpson Highway 149 Ste 370",
            "address_purpose": "LOCATION",
            "city": "Magee",
            "state": "MS",
            "postal_code": "391113843",
            "country_code": "US",
            "telephone_number": "601-849-1530",
            "fax_number": "601-849-1535",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "ST DOMINIC MEDICAL ASSOCIATES LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ST DOMINIC JACKSON MEMORIAL HOSPITAL",
        "enumeration_date": "2014-04-04",
        "last_updated": "2019-07-02",
        "status": "A",
        "authorized_official_last_name": "STUART",
        "authorized_official_first_name": "DANIELLE",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "601-200-4880"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "MS",
            "license": "16442",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St Dominic Raleigh Family Practice",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "St Dominic Raleigh Family Practice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Raleigh, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 2, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.