Healthcare Provider Details

I. General information

NPI: 1649456872
Provider Name (Legal Business Name): MCHENRY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 DELBON AVE SUITE 2
TURLOCK CA
95382-2008
US

IV. Provider business mailing address

1541 FLORIDA AVE SUITE 200
MODESTO CA
95350-4429
US

V. Phone/Fax

Practice location:
  • Phone: 209-634-8556
  • Fax:
Mailing address:
  • Phone: 209-577-3388
  • Fax: 209-342-3743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. HARRIS MICHAEL GOODMAN
Title or Position: CHAIR
Credential: M.D.
Phone: 209-577-3388