Healthcare Provider Details

I. General information

NPI: 1841696192
Provider Name (Legal Business Name): MCKENZIE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 HOSPITAL DR SUITE A
MC KENZIE TN
38201-1649
US

IV. Provider business mailing address

205 HOSPITAL DR SUITE A
MC KENZIE TN
38201-1649
US

V. Phone/Fax

Practice location:
  • Phone: 731-352-7907
  • Fax: 731-352-4459
Mailing address:
  • Phone: 731-352-7907
  • Fax: 731-352-4459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD23833
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD15682
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD46412
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD45034
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1262
License Number StateTN
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN6244
License Number StateTN

VIII. Authorized Official

Name: LISA KAY PAGE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 731-352-7907