1891007431 NPI number — UPPER CUMBERLAND RURAL HEALTH CLINIC PLLC

Table of content: (NPI 1891007431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891007431 NPI number — UPPER CUMBERLAND RURAL HEALTH CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UPPER CUMBERLAND RURAL HEALTH CLINIC PLLC
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:
COOKEVILLE MEDICAL CLINIC GAINESBORO RHC
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:
1891007431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 N WILLOW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COOKEVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38501-2335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-528-8899
Provider Business Mailing Address Fax Number:
931-284-4085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 E GORE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESBORO
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38562-9367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-268-6899
Provider Business Practice Location Address Fax Number:
931-858-8650
Provider Enumeration Date:
07/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JAIN
Authorized Official First Name:
PUSHPENDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
931-528-8899

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: 448904 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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