Healthcare Provider Details

I. General information

NPI: 1205859154
Provider Name (Legal Business Name): MCHENRY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 FLORIDA AVENUE SUITE 200
MODESTO CA
95350
US

IV. Provider business mailing address

1541 FLORIDA AVENUE SUITE 200
MODESTO CA
95350
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-3388
  • Fax: 209-342-3743
Mailing address:
  • Phone: 209-577-3388
  • Fax: 209-342-3743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HARRIS MICHAEL GOODMAN
Title or Position: CHAIR EXECUTIVE COMMITTEE
Credential: MD
Phone: 209-577-3388