NPIMap

Organization Active NPI

St. Dominic Medical Associates LLC

  • Family Medicine Physician
  • Jackson, MS
National Provider Identifier
1407920549
Registry record updated Nov 18, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
ST. DOMINIC MEDICAL ASSOCIATES LLC
Practice address
969 Lakeland Dr
Jackson, MS 39216-4606
Phone
(601) 200-4749
Fax
(601) 200-5929
NPI assigned
Nov 20, 2006
Organization subpart
Yes
Parent organization
ST DOMINC JACKSON MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 18, 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 10

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary
Neurological Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207T00000X
Gynecologic Oncology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207VX0201X
Otolaryngology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Y00000X
Neurology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084N0400X
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X
Surgical Critical Care PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2086S0102X
Urology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208800000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208G00000X
Pain Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208VP0000X

Addresses

Primary practice location

969 Lakeland Dr
Jackson, MS 39216-4606

Mailing address

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

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
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.

National Provider Directory

National Provider Directory
Part of
Chemical Dependency Uni

Member of 1

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

Locations

896 Lakeland Dr
Jackson, MS 39216
Phone (601) 200-3104

971 Lakeland Dr
Ste 250
Jackson, MS 39216
Phone (601) 200-4860

Practitioners 160

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 160

NPI Registry JSON

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

{
    "created_epoch": "1163980800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1637193600000",
    "number": "1407920549",
    "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": "969 LAKELAND DR",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392164606",
            "telephone_number": "601-200-4749",
            "fax_number": "601-200-5929"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. DOMINIC MEDICAL ASSOCIATES LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ST DOMINC JACKSON MEMORIAL HOSPITAL",
        "enumeration_date": "2006-11-20",
        "last_updated": "2021-11-18",
        "certification_date": "2021-11-18",
        "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": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Neurological Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207VX0201X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology, Gynecologic Oncology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Otolaryngology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084N0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2086S0102X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery, Surgical Critical Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208800000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Urology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208G00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208VP0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pain Medicine, Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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 Nov 18, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.