Basic Information
| Provider Information | |||||||||
| NPI: | 1013055912 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COOKEVILLE MEDICAL CENTER PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COOKEVILLE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 225 N WILLOW AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385012335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315288899 | ||||||||
| FaxNumber: | 8668138531 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 N WILLOW AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385012335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315288899 | ||||||||
| FaxNumber: | 8668138531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JAIN | ||||||||
| AuthorizedOfficialFirstName: | PUSHPENDRA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9315288899 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3709492 | 05 | TN | MEDICAID |