NPIMap

Organization Active NPI

St. Dominic Medical Associates, LLC

Doing business as St. Dominic Dermatology

  • Dermatology Physician
  • Madison, MS
National Provider Identifier
1326646845
Registry record updated May 26, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
ST. DOMINIC MEDICAL ASSOCIATES, LLC
Doing business as
St. Dominic Dermatology
Practice address
106 Highland Way Ste 208
Madison, MS 39110-6929
Phone
(601) 200-3376
Fax
(601) 200-4475
NPI assigned
Oct 16, 2020
Last updated
May 26, 2021By 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 May 26, 2021

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
Dermatology Physician 207N00000X Primary

Addresses

Primary practice location

106 Highland Way Ste 208
Madison, MS 39110-6929

Mailing address

PO Box 23666
Jackson, MS 39225-3666
Phone (601) 200-3376

Other names 1

  • St. Dominic Dermatology Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090728000821 MS Part B Supplier - Clinic/Group Practice 0446303168 Receives reassigned benefits from 143 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Raleigh, MS; Madison, MS; Jackson, MS; Flowood, MS; Clinton, MS; Brandon, MS

Other NPIs on the same Medicare enrollment 4

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
25D2228913St Dominic's Dermatology106 Highland Way Ste 203, Madison, MS 39110Provider-performed microscopyJul 1, 2027

National Provider Directory

National Provider Directory
Tax ID family
St Dominic Medical Associates LLC28 organizations share this tax ID, including this one
Part of
Jackson Mental Health

Other organizations with this tax ID 27

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

View all 27

Member of 2

Organizations this organization is a member of, according to the National Provider Directory.

Locations

106 Highland Way
Ste 208
Madison, MS 39110
Phone (601) 200-3376

Practitioners & affiliated clinicians

Practitioners 25

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 25

NPI Registry JSON

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

{
    "created_epoch": "1602806400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1621987200000",
    "number": "1326646845",
    "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": "601-200-3376",
            "fax_number": "601-200-4475"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "106 HIGHLAND WAY STE 208",
            "city": "MADISON",
            "state": "MS",
            "postal_code": "391106929",
            "telephone_number": "601-200-3376",
            "fax_number": "601-200-4475"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. DOMINIC MEDICAL ASSOCIATES, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ST. DOMINIC-JACKSON MEMORIAL HOSPITAL",
        "enumeration_date": "2020-10-16",
        "last_updated": "2021-05-26",
        "certification_date": "2021-05-26",
        "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": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St. Dominic Dermatology",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "St. Dominic Dermatology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Madison, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 26, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.