Basic Information
Provider Information | |||||||||
NPI: | 1467445197 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCHENRY | ||||||||
FirstName: | MALCOLM | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10470 OLD PLACERVILLE RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958272539 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004700071 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2800 L ST | ||||||||
Address2: | 6TH FLOOR | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958165616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9168874040 | ||||||||
FaxNumber: | 9168874045 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2005 | ||||||||
LastUpdateDate: | 09/22/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | G6060 | CA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | G60600 | CA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | P00116899 | 01 | CA | RAIL ROAD MEDICARE PIN | OTHER | 000G60600 | 05 | CA |   | MEDICAID |