NPIMap

Organization Active NPI

Upper Cumberland Rural Health Clinic PLLC

  • Rural Health Clinic/Center
  • Gainesboro, TN
National Provider Identifier
1891007431
Registry record updated Nov 9, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
448904 Issued in TN
Legal business name
UPPER CUMBERLAND RURAL HEALTH CLINIC PLLC
Practice address
402 E Gore Ave
Gainesboro, TN 38562-9367
Phone
(931) 268-6899
Fax
(931) 858-8650
NPI assigned
Jul 12, 2010
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 9, 2022

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

Authorized official

Name
Dr. Pushpendra Jain, MDNPI 1689748634
Title
Ceo
Phone
(931) 528-8899

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
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X 448904 TN Primary

Addresses

Primary practice location

402 E Gore Ave
Gainesboro, TN 38562-9367

Mailing address

225 N Willow Ave
Cookeville, TN 38501-2335
Phone (931) 528-8899

Other names 1

  • Cookeville Medical Clinic Gainesboro RHC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100923000901 TN Part A Provider - Rural Health Clinic 8820198138 Practice locations: Gainesboro, TN

Rural health clinic certification: CCN 448904

Legal name
UPPER CUMBERLAND RURAL HEALTH CLINIC PLLC
Doing business as
COOKEVILLE MEDICAL CLINIC GAINESBORO RHC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 16, 2010
Last certification
Oct 26, 2016
Ownership / control type
1B
Organization structure
LLCNon-profit
Incorporated
Feb 27, 2004 in TN
Enrollment address
402 E Gore Ave
Gainesboro, TN 38562-9367

Other NPIs with the same Medicare PAC ID 8

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
44D1001507Upper Cumberland Rural Health Clinic, PLLC402 East Gore Street, Gainesboro, TN 38562Certificate of waiverJan 14, 2027

National Provider Directory

National Provider Directory
Tax ID family
Baxter Medical Clinic RHC10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

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

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Cookeville Intermediate, PA Organization, Cookeville, TN Corporation 5% Or Greater Direct Ownership Interest Apr 28, 2023 100%
Pushpendra K Jain Individual 5% Or Greater Indirect Ownership Interest Apr 28, 2023 100%
Corporate Officer Jul 15, 2010
Corporate Director Jul 15, 2010
Alexis Barbour Individual Corporate Officer Apr 28, 2023
Navin Jain Individual W-2 Managing EmployeePractice Administrator Jan 1, 2021

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • Pushpendra K Jain, MD
    • Family Medicine Physician
    • Cookeville, TN
    • NPI 1689748634

    5% Or Greater Indirect Ownership Interest, Corporate Director, Corporate Officer

    CMS ownership

Facilities with the same owner 3

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 3

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

NPI Registry JSON

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

{
    "created_epoch": "1278892800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1667952000000",
    "number": "1891007431",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "225 N WILLOW AVE",
            "city": "COOKEVILLE",
            "state": "TN",
            "postal_code": "385012335",
            "telephone_number": "931-528-8899",
            "fax_number": "931-284-4085"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "402 E GORE AVE",
            "city": "GAINESBORO",
            "state": "TN",
            "postal_code": "385629367",
            "telephone_number": "931-268-6899",
            "fax_number": "931-858-8650"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "UPPER CUMBERLAND RURAL HEALTH CLINIC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-07-12",
        "last_updated": "2022-11-09",
        "certification_date": "2022-11-09",
        "status": "A",
        "authorized_official_last_name": "JAIN",
        "authorized_official_first_name": "PUSHPENDRA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "931-528-8899",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "TN",
            "license": "448904",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Cookeville Medical Clinic Gainesboro RHC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Gainesboro, TN

Sources for this page

Verify at the official NPI Registry.