Provider Demographics
NPI:1245401231
Name:MCKENZIE MEDICAL CENTER PC
Entity Type:Organization
Organization Name:MCKENZIE MEDICAL CENTER PC
Other - Org Name:HOMETOWN HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ETHERIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-352-7907
Mailing Address - Street 1:205 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MCKENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201
Mailing Address - Country:US
Mailing Address - Phone:731-352-7907
Mailing Address - Fax:731-325-4459
Practice Address - Street 1:30810 BROAD ST
Practice Address - Street 2:
Practice Address - City:BRUCETON
Practice Address - State:TN
Practice Address - Zip Code:38317-2028
Practice Address - Country:US
Practice Address - Phone:731-586-4800
Practice Address - Fax:731-325-4459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1599152W00000X
TNMD23833207Q00000X, 207Q00000X
261QR1300X, 363A00000X, 363LF0000X
TNAPN15684363LF0000X
TNAPN14751363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380640OtherMEDICAID GROUP
TN3380640OtherMEDICARE GROUP