NPIMap

Organization Active NPI

St Dominic Medical Associates LLC

Doing business as St Dominic Neuroscience Center

  • Neurology Physician
  • Jackson, MS
National Provider Identifier
1215350152
Registry record updated Oct 28, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Neurology PhysicianTaxonomy code 2084N0400X
License
21151 Issued in MS
Legal business name
ST DOMINIC MEDICAL ASSOCIATES LLC
Doing business as
St Dominic Neuroscience Center
Practice address
971 Lakeland Dr
Suite 557
Jackson, MS 39216-4643
Phone
(601) 200-4560
Fax
(601) 200-4850
NPI assigned
Jan 29, 2014
Last updated
Oct 28, 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 Oct 28, 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
Neurology Physician 2084N0400X 21151 MS Primary

Addresses

Primary practice location

971 Lakeland Dr
Suite 557
Jackson, MS 39216-4643

Mailing address

PO Box 23666
Jackson, MS 39225-3666
Phone (601) 200-4560

Other practice location 1

1014 Big Lane Dr
Brookhaven, MS 39601-2331
Phone (601) 200-4560

Other practice location 2

810 E Sunflower Rd Ste 100J
Cleveland, MS 38732-2828
Phone (601) 200-4560

Other practice location 3

4204 Clay St
Vicksburg, MS 39183-3438
Phone (601) 200-4560

Other practice location 4

360 Simpson Highway 149 Ste 370
Magee, MS 39111-3843
Phone (601) 200-4560

Other practice location 5

332 Highway 12 W
Kosciusko, MS 39090-3209
Phone (601) 200-4560

Other identifiers 1

IdentifierTypeStateIssuer
07430597MedicaidMS

Other names 1

  • St Dominic Neuroscience Center 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
St Dominic Hosp

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": "1390953600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1572220800000",
    "number": "1215350152",
    "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": "601-200-4560",
            "fax_number": "601-200-4580"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "971 LAKELAND DR",
            "address_2": "SUITE 557",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392164643",
            "telephone_number": "601-200-4560",
            "fax_number": "601-200-4850"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1014 Big Lane Dr",
            "address_purpose": "LOCATION",
            "city": "Brookhaven",
            "state": "MS",
            "postal_code": "396012331",
            "country_code": "US",
            "telephone_number": "601-200-4560",
            "fax_number": "601-200-4580",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "810 E Sunflower Rd Ste 100J",
            "address_purpose": "LOCATION",
            "city": "Cleveland",
            "state": "MS",
            "postal_code": "387322828",
            "country_code": "US",
            "telephone_number": "601-200-4560",
            "fax_number": "601-200-4580",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "4204 Clay St",
            "address_purpose": "LOCATION",
            "city": "Vicksburg",
            "state": "MS",
            "postal_code": "391833438",
            "country_code": "US",
            "telephone_number": "601-200-4560",
            "fax_number": "601-200-4580",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "360 Simpson Highway 149 Ste 370",
            "address_purpose": "LOCATION",
            "city": "Magee",
            "state": "MS",
            "postal_code": "391113843",
            "country_code": "US",
            "telephone_number": "601-200-4560",
            "fax_number": "601-200-4580",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "332 Highway 12 W",
            "address_purpose": "LOCATION",
            "city": "Kosciusko",
            "state": "MS",
            "postal_code": "390903209",
            "country_code": "US",
            "telephone_number": "601-200-4560",
            "fax_number": "601-200-4580",
            "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": "2014-01-29",
        "last_updated": "2019-10-28",
        "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": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": "MS",
            "license": "21151",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "07430597",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St Dominic Neuroscience Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "St Dominic Neuroscience Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jackson, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 28, 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.