Basic Information
| Provider Information | |||||||||
| NPI: | 1215988324 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCKENZIE TENNESSEE HOSPITAL COMPANY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCKENZIE HOSPITAL CORP ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7100 COMMERCE WAY | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370272829 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 161 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MC KENZIE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382011636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
| FaxNumber: | 6608264852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 02/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 8778929813 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCKENZIE TENNESSEE HOSPITAL COMPANY LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3250180 | 05 | TN | MEDICAID | 4121222 | 01 | TN | BCBS GROUP PIN | OTHER |