NPIMap

Organization Active NPI

McKenzie Medical Center PC

Doing business as Hometown Health Clinic

  • Rural Health Clinic/Center
  • Huntingdon, TN
National Provider Identifier
1144816901
Registry record updated May 6, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MCKENZIE MEDICAL CENTER PC
Doing business as
Hometown Health Clinic
Practice address
205A Court SQ
Huntingdon, TN 38344-3710
Phone
(731) 352-7907
Fax
(833) 690-3848
NPI assigned
Dec 16, 2020
Last updated
May 6, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 6, 2024

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

Authorized official

Name
Tammy Etheridge
Title
Chief Operating Officer
Phone
(731) 352-7907

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

205A Court SQ
Huntingdon, TN 38344-3710

Mailing address

205A Hospital Dr
MC Kenzie, TN 38201-1649
Phone (731) 352-7907

Other names 1

  • Hometown Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040619000083 TN Part B Supplier - Clinic/Group Practice 2365427853 Receives reassigned benefits from 34 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Trenton, TN; McKenzie, TN; MC Kenzie, TN; Huntingdon, TN; Gleason, TN; Dresden, TN; Camden, TN; Bruceton, TN…
O20201229000906 TN Part A Provider - Rural Health Clinic 2365427853 Practice locations: Huntingdon, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1144816901. Details of each certification follow.

Rural health clinic certification: CCN 883847

Legal name
MCKENZIE MEDICAL CENTER PC
Doing business as
HOMETOWN HEALTH CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 24, 2021
Last certification
Jun 24, 2021
Ownership / control type
1C
Organization structure
CorporationProprietary
Enrollment address
205A Court SQ
Huntingdon, TN 38344-3710

Other NPIs with the same Medicare PAC ID 8

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

Other NPIs on the same Medicare enrollment 7

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

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
44D2215303McKenzie Medical Center PC205A Court Square, Huntingdon, TN 38344Certificate of waiverMar 1, 2027

National Provider Directory

National Provider Directory
Tax ID family
McKenzie Medical Center10 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
Jeanene Jones Individual W-2 Managing EmployeeHR Director Jan 1, 2021
WMC Partnership LLC Organization, MC Kenzie, TN LLC 5% Or Greater Direct Ownership Interest Jan 1, 2021
Bryan Hale Merrick Individual 5% Or Greater Direct Ownership Interest Apr 26, 2018
Corporate Officer Apr 26, 2018
Corporate Director Apr 26, 2018
W-2 Managing Employee Apr 26, 2018
Terry Andrew Colotta Individual 5% Or Greater Direct Ownership Interest Apr 26, 2018
Corporate Officer Apr 26, 2018
Corporate Director Apr 26, 2018
W-2 Managing Employee Apr 26, 2018

Owners & managing parties with NPI records 2

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

  • Terry Andrew Colotta, MD
    • Family Medicine Physician
    • McKenzie, TN
    • NPI 1659374296

    5% Or Greater Direct Ownership Interest, Corporate Director, Corporate Officer, W-2 Managing Employee

    CMS ownership
  • Bryan Hale Merrick, MD
    • Internal Medicine Physician
    • McKenzie, TN
    • NPI 1467455287

    5% Or Greater Direct Ownership Interest, Corporate Director, Corporate Officer, W-2 Managing Employee

    CMS ownership

Facilities with the same owner 1

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

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1608076800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1714953600000",
    "number": "1144816901",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "205A HOSPITAL DR",
            "city": "MC KENZIE",
            "state": "TN",
            "postal_code": "382011649",
            "telephone_number": "731-352-7907",
            "fax_number": "833-690-3848"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "205A COURT SQ",
            "city": "HUNTINGDON",
            "state": "TN",
            "postal_code": "383443710",
            "telephone_number": "731-352-7907",
            "fax_number": "833-690-3848"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCKENZIE MEDICAL CENTER PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-12-16",
        "last_updated": "2024-05-06",
        "certification_date": "2024-05-06",
        "status": "A",
        "authorized_official_last_name": "ETHERIDGE",
        "authorized_official_first_name": "TAMMY",
        "authorized_official_title_or_position": "CHIEF OPERATING OFFICER",
        "authorized_official_telephone_number": "731-352-7907"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Hometown Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Hometown Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Huntingdon, TN

Sources for this page

Verify at the official NPI Registry.