McKenzie Medical Center PC
Organization Active NPI Rural Health Clinic/Center · Bruceton, TN
NPI 1245401231 · NPPES record last updated May 6, 2024
Key facts
- NPI
- 1245401231
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- MCKENZIE MEDICAL CENTER PC
- Practice address
- 30810 Broad St
Bruceton, TN 38317-2028 - Phone
- (731) 586-4800
- Fax
- (833) 690-3848
- NPI assigned
- Mar 18, 2008
- Organization subpart
- No
Authorized official
- Name
- Tammy Etheridge
- Title
- Chief Operating Officer
- Phone
- (731) 352-7907
Owners & managing parties with NPI records 2
Other NPIs with the same Medicare PAC ID 8
Practitioners 48
-
Holly Anne Arnold, PA-C
-
Kristin Russell Davis, FNP-BC
-
Rachelle Hale, APRN-BC
-
Tanya Lynn Jackson, FNP-BC
-
Shelby Jo Priddy Chapman, PA-C
-
Dawn Walker, FNP
-
Mary Rebecca Wall, FNP-C
-
Keliea Ann Winstead, PA-C
-
Rachel Nicole Alford, FNP-C
-
Briana Page Chandler, FNP-C
-
Patricia Cunningham, LCSW
-
Leslie Leeann Ellis, FNP
-
Megan Elise Ethredge, LPC/MHSP
-
Hollie Frazier, APN
-
Alicia Graden, NP-C
-
Brady Ray Heath, PA
-
Jami Lane Ivey, LCSW, LADAC
-
Kenneth S Jackson, FNP
-
David Andrew Johnson, MSW, LMFT
-
Hope Newell, PA
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 44D1084883 | Bruceton Clinic,the | Certificate of waiver | Jun 4, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TN
Rural health clinic certification: CCN 883809
- Legal name
- MCKENZIE MEDICAL CENTER PC
- Doing business as
- HOMETOWN HEALTH CLINIC BRUCETON
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Dec 20, 2019
- Last certification
- Apr 28, 2026
- Ownership / control type
- 1B
- Organization structure
- Corporation · Proprietary
- Enrollment address
- 30810 Broad St
Bruceton, TN 38317-2028
All disclosed owners & managing parties 2
| Name | Role | Since | Share |
|---|---|---|---|
| Bryan Hale Merrick |
5% Or Greater Direct Ownership Interest |
Apr 26, 2018 | 50% |
| Corporate Officer |
Apr 26, 2018 | 50% | |
| Corporate Director |
Apr 26, 2018 | ||
| W-2 Managing Employee |
Apr 26, 2018 | ||
| Terry Andrew Colotta |
5% Or Greater Direct Ownership Interest |
Apr 26, 2018 | 50% |
| Corporate Officer |
Apr 26, 2018 | 50% | |
| Corporate Director |
Apr 26, 2018 | 50% | |
| W-2 Managing Employee |
Apr 26, 2018 | 50% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20191021003362 | TN | Part a Provider - Rural Health Clinic | 2365427853 | Practice locations: Bruceton, TN |
National Provider Directory
Locations
105 Cedar LN
Gleason, TN 38229
1894 Cedar St
Mc Kenzie, TN 38201
Phone (731) 207-6496
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist |
152W00000X | ODT1599 | TN | |
| Family Medicine Physician |
207Q00000X | MD23833 | TN | |
| Rural Health Clinic/Center | 261QR1300X | Yes | ||
| Physician Assistant |
363A00000X | |||
| Family Nurse Practitioner |
363LF0000X |
Addresses
Primary practice location
30810 Broad St
Bruceton, TN 38317-2028
Mailing address
205A Hospital Dr
MC Kenzie, TN 38201-1649
Phone (731) 352-7907
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3380640 | Other | TN | MEDICARE GROUP |
| 3380640 | Other | TN | MEDICAID GROUP |
Other names
- Hometown Health Clinic
Other providers in Bruceton, TN
- Danielle Mason
- Jennifer McAdams
- Kylah McDivitt
- Mary McFarlin
- Michelle McGee
- Macy McNabb
- Jasmine Melton
- Milford Medical Investors Limited Partnership
- Geri Miller
- Lakisha Minnis
All providers in Bruceton, TN · Rural Health Clinic/Center in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 6, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.