Provider Demographics
NPI:1104964576
Name:CUMBERLAND PEDIATRIC ASSOCIATES PC
Entity type:Organization
Organization Name:CUMBERLAND PEDIATRIC ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-453-1252
Mailing Address - Street 1:1029 W MAIN ST
Mailing Address - Street 2:SUITE M
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3351
Mailing Address - Country:US
Mailing Address - Phone:615-453-1252
Mailing Address - Fax:615-453-1286
Practice Address - Street 1:1029 W MAIN ST
Practice Address - Street 2:SUITE M
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3351
Practice Address - Country:US
Practice Address - Phone:615-453-1252
Practice Address - Fax:615-453-1286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2025-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3713897Medicaid