NPIMap

Organization Active NPI

McKenzie Medical Center PC

Doing business as Hometown Health Clinic

  • Rural Health Clinic/Center
  • Bruceton, TN
National Provider Identifier
1245401231
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
30810 Broad St
Bruceton, TN 38317-2028
Phone
(731) 586-4800
Fax
(833) 690-3848
NPI assigned
Mar 18, 2008
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 5

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X ODT1599 TN
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X MD23833 TN
Rural Health Clinic/Center 261QR1300X Primary
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 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 names 1

  • Hometown Health Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20191021003362 TN Part A Provider - Rural Health Clinic 2365427853 Practice locations: Bruceton, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1245401231. Details of each certification follow.

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
CorporationProprietary
Enrollment address
30810 Broad St
Bruceton, TN 38317-2028

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
44D1084883Bruceton Clinic,the30810 Broad Street, Bruceton, TN 38317Certificate of waiverJun 4, 2028

National Provider Directory

National Provider Directory

Locations

105 Cedar LN
Gleason, TN 38229

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Bryan Hale Merrick Individual 5% Or Greater Direct Ownership InterestPartner Apr 26, 2018 50%
Corporate OfficerPartner Apr 26, 2018 50%
Corporate DirectorPartner Apr 26, 2018
W-2 Managing EmployeePartner Apr 26, 2018
Terry Andrew Colotta Individual 5% Or Greater Direct Ownership InterestPartner Apr 26, 2018 50%
Corporate OfficerPartner Apr 26, 2018 50%
Corporate DirectorPartner Apr 26, 2018 50%
W-2 Managing EmployeePartner Apr 26, 2018 50%

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

Practitioners & affiliated clinicians

Practitioners 26

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.

View all 26

NPI Registry JSON

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

{
    "created_epoch": "1205798400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1714953600000",
    "number": "1245401231",
    "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": "30810 BROAD ST",
            "city": "BRUCETON",
            "state": "TN",
            "postal_code": "383172028",
            "telephone_number": "731-586-4800",
            "fax_number": "833-690-3848"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCKENZIE MEDICAL CENTER PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-03-18",
        "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": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": "TN",
            "license": "ODT1599",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "TN",
            "license": "MD23833",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Hometown Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bruceton, TN

Sources for this page

Verify at the official NPI Registry.