McKenzie Medical Center PC
Organization Active NPI Rural Health Clinic/Center · MC Kenzie, TN
NPI 1477516953 · NPPES record last updated Dec 3, 2024
Key facts
- NPI
- 1477516953
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- MCKENZIE MEDICAL CENTER PC
- Practice address
- 205A Hospital Dr
MC Kenzie, TN 38201-1649 - Phone
- (731) 352-7907
- Fax
- (833) 690-3848
- NPI assigned
- Apr 7, 2006
- 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 on the same Medicare enrollment 7
Other NPIs with the same Medicare PAC ID 8
Practitioners 41
-
Holly Anne Arnold, PA-C
-
Briana Page Chandler, FNP-C
-
Patricia Cunningham, LCSW
-
Kristin Russell Davis, FNP-BC
-
Megan Elise Ethredge, LPC/MHSP
-
Hollie Frazier, APN
-
Alicia Graden, NP-C
-
Rachelle Hale, APRN-BC
-
Brady Ray Heath, PA
-
Jami Lane Ivey, LCSW, LADAC
-
Kenneth S Jackson, FNP
-
Tanya Lynn Jackson, FNP-BC
-
David Andrew Johnson, MSW, LMFT
-
Hope Newell, PA
-
Shelby Jo Priddy Chapman, PA-C
-
Matthew W Roberts, FNP-C
-
Jonathan E Searcy, LCSW
-
Cristie Anne Vibbert, FNP-BC
-
Mark Vinson, FNP-BC
-
Bobbie Walker, FNP-C
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TN
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
- Corporation · Proprietary
- Enrollment address
- 205A Hospital Dr
MC Kenzie, TN 38201-2024
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 | 50% | |
| W-2 Managing Employee |
Apr 26, 2018 | 50% | |
| 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 |
|---|---|---|---|---|
| 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 |
National Provider Directory
Locations
30810 Broad St
Bruceton, TN 38317
Phone (731) 586-4800
205A Hospital Dr
#A
Mc Kenzie, TN 38201
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker |
1041C0700X | LSW5620 | TN | |
| Marriage & Family Therapist |
106H00000X | LMFT917 | TN | |
| Optometrist |
152W00000X | ODT441 | TN | |
| Internal Medicine Physician |
207R00000X | MD15682 | TN | |
| Pediatrics Physician |
208000000X | MD46412 | TN | |
| Rural Health Clinic/Center | 261QR1300X | Yes | ||
| Physician Assistant |
363A00000X | PA1503 | TN | |
| Family Nurse Practitioner |
363LF0000X | APN6244 | TN | |
| Psychiatric/Mental Health Nurse Practitioner |
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 identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3380640 | Other | TN | GROUP MEDICARE |
| 3380640 | Other | TN | GROUP MEDICAID |
Other names
- Hometown Health Clinic
Other providers in MC Kenzie, TN
- McKenzie Healthcare and Rehabilitation Center LLC
- McKenzie Medical Center
- McKenzie Medical Center
- McKenzie Medical Center Lab
- McKenzie Medical Center PC
- McKenzie Medical Center PC
- McKenzie Medical Center PC
- McKenzie SNF Healthcare LLC
- McKenzie Tennessee Hospital Company LLC
- McKenzie Tennessee Hospital Company LLC
All providers in MC Kenzie, 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 Dec 3, 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.