Basic Information
| Provider Information | |||||||||
| NPI: | 1407827157 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCKENZIE TENNESSEE HOSPITAL COMPANY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MCKENZIE REGIONAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 501092 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631501092 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 161 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MC KENZIE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382011636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7313525344 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUSSEY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP, GROUP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8883739600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0000000011 | TN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 25796 | 05 | TN | MEDICAID | 440008 | 05 | TN | MEDICAID | 4050785 | 01 | BCBS | OTHER | 136768 | 05 | TN | MEDICAID | 26664 | 05 | TN | MEDICAID | 0440182 | 05 | TN | MEDICAID |