Basic Information
| Provider Information | |||||||||
| NPI: | 1891007431 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UPPER CUMBERLAND RURAL HEALTH CLINIC PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COOKEVILLE MEDICAL CLINIC GAINESBORO RHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 225 N WILLOW AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385012335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315288899 | ||||||||
| FaxNumber: | 9312844085 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 E GORE AVE | ||||||||
| Address2: | |||||||||
| City: | GAINESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385629367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312686899 | ||||||||
| FaxNumber: | 9318588650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2010 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JAIN | ||||||||
| AuthorizedOfficialFirstName: | PUSHPENDRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9315288899 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | 448904 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.