NPIMap

Organization Active NPI

McKenzie Medical Center PC

Doing business as Hometown Health Clinic

  • Rural Health Clinic/Center
  • McKenzie, TN
National Provider Identifier
1477516953
Registry record updated Dec 3, 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 Hospital Dr
MC Kenzie, TN 38201-1649
Phone
(731) 352-7907
Fax
(833) 690-3848
NPI assigned
Apr 7, 2006
Last updated
Dec 3, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 3, 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 9

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X LSW5620 TN
Marriage & Family TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 106H00000X LMFT917 TN
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X ODT441 TN
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X MD15682 TN
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X MD46412 TN
Rural Health Clinic/Center 261QR1300X Primary
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X PA1503 TN
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X APN6244 TN
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X

Addresses

Primary practice location

205A Hospital Dr
MC Kenzie, TN 38201-1649

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…
O20200225000811 TN Part A Provider - Rural Health Clinic 2365427853 Practice locations: MC Kenzie, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1477516953. Details of each certification follow.

Rural health clinic certification: CCN 883816

Legal name
MCKENZIE MEDICAL CENTER PC
Doing business as
HOMETOWN HEALTH CLINIC MCKENZIE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 16, 2020
Last certification
Apr 16, 2020
Ownership / control type
1C
Organization structure
CorporationProprietary
Enrollment address
205A Hospital Dr
MC Kenzie, TN 38201-2024

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.

National Provider Directory

National Provider Directory

Locations

30810 Broad St
Bruceton, TN 38317
Phone (731) 586-4800

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

205A Hospital Dr
#A
Mc Kenzie, TN 38201

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 Director Apr 26, 2018 50%
W-2 Managing EmployeePartner Apr 26, 2018 50%
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 37

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 37

NPI Registry JSON

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

{
    "created_epoch": "1144368000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1733184000000",
    "number": "1477516953",
    "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 HOSPITAL DR",
            "city": "MC KENZIE",
            "state": "TN",
            "postal_code": "382011649",
            "telephone_number": "731-352-7907",
            "fax_number": "833-690-3848"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCKENZIE MEDICAL CENTER PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-07",
        "last_updated": "2024-12-03",
        "certification_date": "2024-12-03",
        "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": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "TN",
            "license": "LSW5620",
            "primary": false
        },
        {
            "code": "106H00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Marriage & Family Therapist",
            "state": "TN",
            "license": "LMFT917",
            "primary": false
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": "TN",
            "license": "ODT441",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "TN",
            "license": "MD15682",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": "TN",
            "license": "MD46412",
            "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": "TN",
            "license": "PA1503",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "TN",
            "license": "APN6244",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Hometown Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in McKenzie, TN

Sources for this page

Verify at the official NPI Registry.