Healthcare Provider Details

I. General information

NPI: 1679195036
Provider Name (Legal Business Name): MCKENZIE MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205C HOSPITAL DR
MC KENZIE TN
38201-1649
US

IV. Provider business mailing address

205A HOSPITAL DR
MC KENZIE TN
38201-1649
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

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