1407025711 NPI number — DAVID ALAN TIMM

Table of content: (NPI 1407025711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407025711 NPI number — DAVID ALAN TIMM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID ALAN TIMM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PEDIATRIC & ADOLESCENT CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407025711
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
308 HIGHLAND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NATCHEZ
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39120-4611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-442-7676
Provider Business Mailing Address Fax Number:
601-442-9590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1806 CARTER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71373-3115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-336-7172
Provider Business Practice Location Address Fax Number:
318-336-7172
Provider Enumeration Date:
02/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RIFE
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
BUSINESS MGR
Authorized Official Telephone Number:
601-442-7676

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1021849 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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