NPIMap

Organization Active NPI

McKenzie Medical Center, PC

Doing business as Hometown Health Clinic

  • Rural Health Clinic/Center
  • Dresden, TN
National Provider Identifier
1609101534
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
811 Morrow St Ste 207
Dresden, TN 38225-1847
Phone
(731) 364-4900
Fax
(833) 690-3848
NPI assigned
Oct 9, 2009
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 6

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X NU
Rural Health Clinic/Center 261QR1300X NU Primary
Physician Assistant 363A00000X PA1262 TN
Family Nurse Practitioner 363LF0000X APN14751 TN
Optometrist 152W00000X ODT1599 TN
Family Medicine Physician 207Q00000X MD23833 TN

Addresses

Primary practice location

811 Morrow St Ste 207
Dresden, TN 38225-1847

Mailing address

205A Hospital Dr
MC Kenzie, TN 38201-1649
Phone (731) 352-7907

Other identifiers 3

IdentifierTypeStateIssuer
3380640OtherTNGROUP MEDICARE NUMBER
3380640OtherTNGROUP MEDICAID NUMBER
Q018764MedicaidTN

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…
O20191101000264 TN Part A Provider - Rural Health Clinic 2365427853 Practice locations: Dresden, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1609101534. Details of each certification follow.

Rural health clinic certification: CCN 883812

Legal name
MCKENZIE MEDICAL CENTER PC
Doing business as
HOMETOWN HEALTH CLINIC DRESDEN
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 10, 2020
Last certification
Apr 30, 2026
Ownership / control type
1B
Organization structure
CorporationProprietary
Enrollment address
811 Morrow St
Ste 207
Dresden, TN 38225-1847

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

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 Sep 1, 2019
Corporate DirectorPartner Sep 1, 2019
W-2 Managing EmployeePartner Sep 1, 2019
Terry Andrew Colotta Individual 5% Or Greater Direct Ownership InterestPartner Apr 26, 2018 50%
Corporate OfficerPartner Sep 1, 2019
Corporate DirectorPartner Sep 1, 2019
W-2 Managing EmployeePartner Sep 1, 2019

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 8

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.

NPI Registry JSON

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

{
    "created_epoch": "1255046400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1714953600000",
    "number": "1609101534",
    "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": "811 MORROW ST STE 207",
            "city": "DRESDEN",
            "state": "TN",
            "postal_code": "382251847",
            "telephone_number": "731-364-4900",
            "fax_number": "833-690-3848"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCKENZIE MEDICAL CENTER, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-10-09",
        "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": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "TN",
            "license": "PA1262",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "TN",
            "license": "APN14751",
            "primary": false
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "TN",
            "license": "ODT1599",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "TN",
            "license": "MD23833",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP MEDICARE NUMBER",
            "identifier": "3380640",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP MEDICAID NUMBER",
            "identifier": "3380640",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "Q018764",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Hometown Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dresden, TN

Sources for this page

Verify at the official NPI Registry.