Basic Information
| Provider Information | |||||||||
| NPI: | 1194162552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCHENRY | ||||||||
| FirstName: | HARRY | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 571 SAINT JOSEPHS BLVD | ||||||||
| Address2: | FL 2 | ||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1138 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149042502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077347982 | ||||||||
| FaxNumber: | 6077341953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2013 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS018120 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 290308 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04428020 | 05 | NY | MEDICAID |