Provider Demographics
NPI:1033210315
Name:NATCHEZ PEDIATRIC CLINIC PLLC
Entity Type:Organization
Organization Name:NATCHEZ PEDIATRIC CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-442-5439
Mailing Address - Street 1:PO BOX 17918
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39122-7918
Mailing Address - Country:US
Mailing Address - Phone:601-442-5439
Mailing Address - Fax:601-442-3755
Practice Address - Street 1:136 JEFFERSON DAVIS BLVD.
Practice Address - Street 2:SUITE A
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120
Practice Address - Country:US
Practice Address - Phone:601-442-5439
Practice Address - Fax:601-442-3755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015226Medicaid
LA1445967Medicaid