Healthcare Provider Details

I. General information

NPI: 1952163206
Provider Name (Legal Business Name): PEDIATRIC & ADOLESCENT CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2024
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N MARTIN LUTHER KING JR ST
NATCHEZ MS
39120-3356
US

IV. Provider business mailing address

308 HIGHLAND BLVD
NATCHEZ MS
39120-4611
US

V. Phone/Fax

Practice location:
  • Phone: 601-442-7676
  • Fax: 601-442-9590
Mailing address:
  • Phone: 601-442-7676
  • Fax: 601-442-9590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID A TIMM
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 601-442-7676