NPIMap

Organization Active NPI

David Alan Timm

Doing business as Pediatric & Adolescent Clinic

  • Rural Health Clinic/Center
  • Natchez, MS
National Provider Identifier
1366890238
Registry record updated May 10, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
DAVID ALAN TIMM
Doing business as
Pediatric & Adolescent Clinic
Practice address
308 Highland Blvd
Natchez, MS 39120-4611
Phone
(601) 442-7676
NPI assigned
Jun 1, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 10, 2021

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

Authorized official

Name
Dr. David Alan Timm, M.D.NPI 1023194867
Title
Owner
Phone
(601) 442-7676

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X MS Primary

Addresses

Primary practice location

308 Highland Blvd
Natchez, MS 39120-4611

Mailing address

308 Highland Blvd
Natchez, MS 39120-4611
Phone (601) 442-7676

Other names 1

  • Pediatric & Adolescent Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170112002400 MS Part A Provider - Rural Health Clinic 3870788722 Practice locations: Natchez, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1366890238. Details of each certification follow.

Rural health clinic certification: CCN 253932

Legal name
DAVID ALAN TIMM
Doing business as
PEDIATRIC & ADOLESCENT CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 19, 2017
Last certification
Oct 19, 2017
Ownership / control type
1A
Organization structure
Sole ProprietorProprietary
Enrollment address
308 Highland Blvd
Natchez, MS 39120-4611

National Provider Directory

National Provider Directory
Tax ID family
David Alan Timm4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
David Alan Timm Individual 5% Or Greater Direct Ownership Interest Mar 14, 2015 100%
Corporate DirectorMedical Director Mar 14, 2015 100%
W-2 Managing Employee Jul 1, 2021

Practitioners & affiliated clinicians

Practitioners 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1464739200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1620604800000",
    "number": "1366890238",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "308 HIGHLAND BLVD",
            "city": "NATCHEZ",
            "state": "MS",
            "postal_code": "391204611",
            "telephone_number": "601-442-7676"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "308 HIGHLAND BLVD",
            "city": "NATCHEZ",
            "state": "MS",
            "postal_code": "391204611",
            "telephone_number": "601-442-7676"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DAVID ALAN TIMM",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-06-01",
        "last_updated": "2021-05-10",
        "certification_date": "2021-05-10",
        "status": "A",
        "authorized_official_last_name": "TIMM",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "ALAN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "601-442-7676",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MS",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pediatric & Adolescent Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Natchez, MS

Sources for this page

Verify at the official NPI Registry.