Basic Information
| Provider Information | |||||||||
| NPI: | 1689748634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAIN | ||||||||
| FirstName: | PUSHPENDRA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 N WILLOW AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385012335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315288899 | ||||||||
| FaxNumber: | 9315207655 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 N WILLOW AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385012335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315288899 | ||||||||
| FaxNumber: | 9315207655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD16449 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3863723 | 05 | TN | MEDICAID | 3018160 | 05 | TN | MEDICAID |