NPIMap

Organization Active NPI

Cumberland Pediatric Associates PC

  • Rural Health Clinic/Center
  • Lebanon, TN
National Provider Identifier
1104964576
Registry record updated Jul 29, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CUMBERLAND PEDIATRIC ASSOCIATES PC
Practice address
1029 W Main St
Suite M
Lebanon, TN 37087-3351
Phone
(615) 453-1252
Fax
(615) 453-1286
NPI assigned
Feb 1, 2007
Last updated
Jul 29, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 29, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Charles Andrew Jordan, MDNPI 1083784235
Title
Physician
Phone
(615) 453-1252

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

1029 W Main St
Suite M
Lebanon, TN 37087-3351

Mailing address

1029 W Main St
Suite M
Lebanon, TN 37087-3351
Phone (615) 453-1252

Other practice location 1

333 McMurry Blvd E
Hartsville, TN 37074-1215
Phone (615) 549-7737

Other practice location 2

8 New Middleton Hwy
Gordonsville, TN 38563-6603
Phone (615) 683-4200

Other identifiers 1

IdentifierTypeStateIssuer
3713897MedicaidTN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20210628001819 TN Part A Provider - Rural Health Clinic 6305247446 Practice locations: Gordonsville, TN
O20250404002236 TN Part A Provider - Rural Health Clinic 6305247446 Practice locations: Lebanon, TN

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1104964576. Details of each certification follow.

Rural health clinic certification: CCN 883858

Legal name
CUMBERLAND PEDIATRIC ASSOCIATES PC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 20, 2021
Last certification
Dec 20, 2021
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Aug 10, 1999 in TN
Enrollment address
8 New Middleton Hwy
Gordonsville, TN 38563-6603

Rural health clinic certification: CCN 888935

Legal name
CUMBERLAND PEDIATRIC ASSOCIATES PC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 20, 2025
Last certification
May 20, 2025
Ownership / control type
1B
Organization structure
CorporationProprietary
Enrollment address
1029 W Main St
Ste M
Lebanon, TN 37087-3347

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
44D0968256Cumberland Pediatric Associates PLLC1029 West Main Street, Suite M, Lebanon, TN 37087Certificate of waiverJul 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Cumberland Pediatric Associates PC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1029 W Main St
Ste M
Lebanon, TN 37087
Phone (615) 453-1252

1029 W Main St
Ste O
Lebanon, TN 37087
Phone (615) 453-1252

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Charles Jordan Individual 5% Or Greater Direct Ownership InterestPresident Jun 1, 2021
Corporate OfficerPresident Jun 1, 2021
Operational/Managerial ControlPresident Jun 1, 2021
5% Or Greater Direct Ownership InterestPresident Aug 10, 1999 100%
Corporate OfficerPresident Aug 10, 1999 100%
W-2 Managing EmployeePresident Aug 10, 1999 100%
Operational/Managerial ControlPresident Aug 10, 1999 100%

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170288000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1785283200000",
    "number": "1104964576",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1029 W MAIN ST",
            "address_2": "SUITE M",
            "city": "LEBANON",
            "state": "TN",
            "postal_code": "370873351",
            "telephone_number": "615-453-1252",
            "fax_number": "615-453-1286"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1029 W MAIN ST",
            "address_2": "SUITE M",
            "city": "LEBANON",
            "state": "TN",
            "postal_code": "370873351",
            "telephone_number": "615-453-1252",
            "fax_number": "615-453-1286"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "333 McMurry Blvd E",
            "address_purpose": "LOCATION",
            "city": "Hartsville",
            "state": "TN",
            "postal_code": "370741215",
            "country_code": "US",
            "telephone_number": "615-549-7737",
            "fax_number": "615-549-7734",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "8 New Middleton Hwy",
            "address_purpose": "LOCATION",
            "city": "Gordonsville",
            "state": "TN",
            "postal_code": "385636603",
            "country_code": "US",
            "telephone_number": "615-683-4200",
            "fax_number": "615-683-4207",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "CUMBERLAND PEDIATRIC ASSOCIATES PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-01",
        "last_updated": "2026-07-29",
        "certification_date": "2026-07-29",
        "status": "A",
        "authorized_official_last_name": "JORDAN",
        "authorized_official_first_name": "CHARLES",
        "authorized_official_middle_name": "ANDREW",
        "authorized_official_title_or_position": "PHYSICIAN",
        "authorized_official_telephone_number": "615-453-1252",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3713897",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lebanon, TN

Sources for this page

Verify at the official NPI Registry.