NPIMap

Organization Active NPI

McKenzie Medical Center, PC

Doing business as Hometown Health Clinic

  • Rural Health Clinic/Center
  • Camden, TN
National Provider Identifier
1376188045
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
306 Highway 641 N
Camden, TN 38320-3012
Phone
(731) 586-4800
Fax
(833) 690-3848
NPI assigned
Nov 16, 2019
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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary
Family Medicine Physician 207Q00000X NU

Addresses

Primary practice location

306 Highway 641 N
Camden, TN 38320-3012

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
O20200305001384 TN Part A Provider - Rural Health Clinic 2365427853 Practice locations: Camden, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1376188045. Details of each certification follow.

Rural health clinic certification: CCN 883815

Legal name
MCKENZIE MEDICAL CENTER PC
Doing business as
HOMETOWN HEALTH CLINIC CAMDEN
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 17, 2020
Last certification
Apr 17, 2020
Ownership / control type
1C
Organization structure
CorporationProprietary
Enrollment address
306 Highway 641 N
Camden, TN 38320-3012

Other NPIs with the same Medicare PAC ID 8

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

National Provider Directory

National Provider Directory

Locations

306 Highway 641 N
Camden, TN 38320
Phone (731) 213-2344

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
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
Corporate DirectorPartner Apr 26, 2018
W-2 Managing EmployeePartner 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

NPI Registry JSON

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

{
    "created_epoch": "1573862400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1714953600000",
    "number": "1376188045",
    "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": "731-352-4459"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "306 HIGHWAY 641 N",
            "city": "CAMDEN",
            "state": "TN",
            "postal_code": "383203012",
            "telephone_number": "731-586-4800",
            "fax_number": "833-690-3848"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCKENZIE MEDICAL CENTER, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-11-16",
        "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
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Hometown Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Camden, TN

Sources for this page

Verify at the official NPI Registry.