Covenant Pediatrics, PLLC

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

License

MD19704 Issued in TN

Legal business name

COVENANT PEDIATRICS, PLLC

Practice address

421 Old Riceville Rd Ste 2
Athens, TN 37303-3074

Phone

(423) 744-8755

Fax

(423) 744-8568

NPI assigned

Mar 19, 2011

Organization subpart

No

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

Authorized official

Name

Omer Breeden

Title

Business Manager

Phone

(423) 744-8755

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TN

Enrollment records 1

Rural health clinic certification: CCN 448926

Legal name

COVENANT PEDIATRICS, PLLC

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Oct 28, 2013

Last certification

May 22, 2019

Ownership / control type

1A

Organization structure

LLCProprietary

Enrollment address

421 Old Riceville Rd
Ste 2
Athens, TN 37303-3074

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

CLIA laboratory certificates

Locations

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.

Change-of-ownership history 1

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

• Kimberly Thompson Breeden, MD

  • Pediatrics Physician
  • Athens, TN
  • NPI 1619920303

  Acquired from, 2018-01-01

  CMS change of ownership

Practitioners 8

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

• Kimberly Thompson Breeden, MD

  • Pediatrics Physician
  • Athens, TN
  • NPI 1619920303

  Pediatrics

  NPD
• Simon Bessette, PA-C

  • Physician Assistant
  • Athens, TN
  • NPI 1942767264
  NPD (past)
• Constance F Cowherd, ANP

  • Pediatric Nurse Practitioner
  • Athens, TN
  • NPI 1275764847
  NPD (past)
• Elizabeth A Cruttenden, NP-C

  • Pediatric Nurse Practitioner
  • Athens, TN
  • NPI 1326271370
  NPD (past)
• Mia Bettina Feliciano Matias, M.D.

  • Pediatrics Physician
  • Athens, TN
  • NPI 1093838401

  Pediatrics

  NPD (past)
• Susan Kimberly Moore Rucker, MD

  • Pediatrics Physician
  • Athens, TN
  • NPI 1104967306

  Pediatrics

  NPD (past)
• Hari Mahefa Ratsimbason, M.D.

  • Pediatrics Physician
  • Athens, TN
  • NPI 1417190331

  Pediatrics

  NPD (past)
• Regena Shelton, APN

  • Pediatric Nurse Practitioner
  • Athens, TN
  • NPI 1811368830
  NPD (past)

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

{
    "created_epoch": "1300492800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1653264000000",
    "number": "1659670412",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "421 OLD RICEVILLE RD STE 2",
            "city": "ATHENS",
            "state": "TN",
            "postal_code": "373033074",
            "telephone_number": "423-744-8755",
            "fax_number": "423-744-8568"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "421 OLD RICEVILLE RD STE 2",
            "city": "ATHENS",
            "state": "TN",
            "postal_code": "373033074",
            "telephone_number": "423-744-8755",
            "fax_number": "423-744-8568"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COVENANT PEDIATRICS, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-19",
        "last_updated": "2022-05-23",
        "certification_date": "2022-05-23",
        "status": "A",
        "authorized_official_last_name": "BREEDEN",
        "authorized_official_first_name": "OMER",
        "authorized_official_title_or_position": "BUSINESS MANAGER",
        "authorized_official_telephone_number": "423-744-8755"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "TN",
            "license": "MD19704",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Hamir Dharnidhar Contractor, D.D.S.
• Corbin Cook
• Melanie Cook, CCC-SLP
• Llewellyn Cooper, PH.D
• Sheena M Cotten, DPT
• Constance F Cowherd, ANP
• Charles Boggess Cox, M.D.
• Janice Hughes Crabtree, R.N
• Allison Jill Crisp, DPT, MTC
• Chastity Donielle Croft, CNA

• Rural Health Clinic/Center in Athens, TN
• Providers in Athens, TN by specialty
• Rural Health Clinic/Center in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 23, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.