Cumberland Pediatric Associates PC

Key facts

NPI: 1366174161
Entity type: Organization (NPI type 2)
Primary specialty: Rural Health Clinic/Center 261QR1300X
Legal business name: CUMBERLAND PEDIATRIC ASSOCIATES PC
Practice address: 333 McMurry Blvd E
Hartsville, TN 37074-1215
Phone: (615) 549-7737
Fax: (615) 549-7734
NPI assigned: Jun 29, 2022
Organization subpart: No

Authorized official

Name: Tatianna Dvornik
Title: Associate Regional Director
Phone: (615) 453-1252

Other NPIs with the same Medicare PAC ID 1

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

Cumberland Pediatric Associates PC Rural Health Clinic/Center · Lebanon, TN · NPI 1104964576

Same PAC ID 6305247446

Corporate family (same tax ID) 2

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

Cumberland Pediatric Associates PC Rural Health Clinic/Center · Lebanon, TN · NPI 1104964576

NPD tax ID
Cumberland Pediatric Associates PC Rural Health Clinic/Center · Gordonsville, TN · NPI 1205568003

NPD tax ID

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Miranda Annette Green, FNP-C Family Nurse Practitioner · Gallatin, TN · NPI 1508393430

NPD (past)

Medicare participation

Medicare fee-for-service enrollment: Enrolled in TN

Rural health clinic certification: CCN 883934

Legal name: CUMBERLAND PEDIATRIC ASSOCIATES PC
Certification status: Active
Provider type (POS): Rural health clinic
Participating since: Feb 16, 2023
Last certification: Feb 16, 2023
Ownership / control type: 1B
Organization structure: Corporation · Proprietary
Incorporated: Aug 10, 1999 in TN
Enrollment address: 333 McMurry Blvd E
Hartsville, TN 37074-1215

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.

Name	Role	Since	Share
Charles Jordan Individual	5% Or Greater Direct Ownership Interest	Aug 10, 1999	100%
	Corporate Officer President	Aug 10, 1999	100%
	Operational/Managerial Control President	Aug 10, 1999	100%

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
O20220825001413	TN	Part a Provider - Rural Health Clinic	6305247446	Practice locations: Hartsville, TN

National Provider Directory

Tax ID family: Cumberland Pediatric Associates PC (3 organizations share this tax ID)

Locations

333 McMurry Blvd E
Hartsville, TN 37074
Phone (615) 374-3500

Specialties & licenses

Specialty (taxonomy)	Code	Primary
Pediatrics Physician Group: 193400000X SINGLE SPECIALTY GROUP	208000000X
Clinic/Center	261Q00000X
Rural Health Clinic/Center	261QR1300X	Yes

Addresses

Primary practice location

333 McMurry Blvd E
Hartsville, TN 37074-1215

Mailing address

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

Other names

Cumberland Pediatric Associates PC Hartsville Other name

Other providers in Hartsville, TN

All providers in Hartsville, 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.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.