=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841696192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCKENZIE MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2014
-----------------------------------------------------
Last Update Date | 10/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 HOSPITAL DR SUITE A
-----------------------------------------------------
City | MC KENZIE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38201-1649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-352-7907
-----------------------------------------------------
Fax | 731-352-4459
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 HOSPITAL DR SUITE A
-----------------------------------------------------
City | MC KENZIE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38201-1649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-352-7907
-----------------------------------------------------
Fax | 731-352-4459
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | LISA KAY PAGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 731-352-7907
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD15682
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD23833
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD46412
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | MD45034
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA1262
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APN6244
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------