Healthcare Provider Details

I. General information

NPI: 1609101534
Provider Name (Legal Business Name): MCKENZIE MEDICAL CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2009
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 MORROW ST STE 207
DRESDEN TN
38225-1847
US

IV. Provider business mailing address

205A HOSPITAL DR
MC KENZIE TN
38201-1649
US

V. Phone/Fax

Practice location:
  • Phone: 731-364-4900
  • Fax: 833-690-3848
Mailing address:
  • Phone: 731-352-7907
  • Fax: 731-352-4459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1262
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN14751
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODT1599
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD23833
License Number StateTN

VIII. Authorized Official

Name: TAMMY ETHERIDGE
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 731-352-7907