Cumberland Pediatric Associates PC
Organization Active NPI Rural Health Clinic/Center · Lebanon, TN
NPI 1104964576 · NPPES record last updated Jul 29, 2026
Key facts
- NPI
- 1104964576
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 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
- Organization subpart
- No
Authorized official
- Name
- Charles Andrew Jordan, MD
- Title
- Physician
- Phone
- (615) 453-1252
Other NPIs with the same Medicare PAC ID 1
Corporate family (same tax ID) 2
Practitioners 7
-
Madison Kane Bears, PNP
-
Margaret Allison Davis, MSN, APRN, CPNP-PC
-
Amy Alicia Evans, RN, FNP-BC
-
Miranda Annette Green, FNP-C
-
Larryl C Spearmon, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 44D0968256 | Cumberland Pediatric Associates PLLC | Certificate of waiver | Jul 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TN
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
- Corporation · Proprietary
- 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
- Corporation · Proprietary
- Enrollment address
- 1029 W Main St
Ste M
Lebanon, TN 37087-3347
All disclosed owners & managing parties 1
| Name | Role | Since | Share |
|---|---|---|---|
| Charles Jordan |
5% Or Greater Direct Ownership Interest |
Jun 1, 2021 | |
| Corporate Officer |
Jun 1, 2021 | ||
| Operational/Managerial Control |
Jun 1, 2021 | ||
| 5% Or Greater Direct Ownership Interest |
Aug 10, 1999 | 100% | |
| Corporate Officer |
Aug 10, 1999 | 100% | |
| W-2 Managing Employee |
Aug 10, 1999 | 100% | |
| Operational/Managerial Control |
Aug 10, 1999 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
- Tax ID family
- Cumberland Pediatric Associates PC
Locations
1029 W Main St
Ste M
Lebanon, TN 37087
Phone (615) 453-1252
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Primary Care Clinic/Center | 261QP2300X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes |
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
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3713897 | Medicaid | TN |
Other providers in Lebanon, TN
- Lauren Crotzer
- Samuel John Crutcher
- Britney Cuevas
- Cumberland Ambulatory Physicians PC
- Cumberland Chiropractic and Sports Medicine, LLC
- Cumberland Skin Surgery and Dermatology
- Lauren Cummings
- Isabella Rose Curcio
- Amanda Curtis
- D & O Group LLC
All providers in Lebanon, TN · Rural Health Clinic/Center in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 29, 2026. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.