Provider Demographics
NPI:1841696192
Name:MCKENZIE MEDICAL CENTER
Entity type:Organization
Organization Name:MCKENZIE MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-352-7907
Mailing Address - Street 1:205 HOSPITAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1649
Mailing Address - Country:US
Mailing Address - Phone:731-352-7907
Mailing Address - Fax:731-352-4459
Practice Address - Street 1:205 HOSPITAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-1649
Practice Address - Country:US
Practice Address - Phone:731-352-7907
Practice Address - Fax:731-352-4459
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCKENZIE MEDICAL CENTER, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-14
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD15682207R00000X
TNMD23833207Q00000X
TNMD46412208000000X, 208000000X
TNMD45034208600000X, 208600000X
TNPA1262363A00000X
TNAPN6244363LF0000X
261QU0200X
TNMD11366208D00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380640OtherGROUP MEDICAID
TN3380640OtherGROUP MEDICARE