Basic Information
| Provider Information | |||||||||
| NPI: | 1053550715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERITAGE MEDICAL GROUP, LLP | ||||||||
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| OtherOrganizationName: | PA NEUROLOGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 WALNUT ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | LEMOYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170431168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177610208 | ||||||||
| FaxNumber: | 7177612023 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 LOWTHER ST | ||||||||
| Address2: | |||||||||
| City: | LEMOYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170432012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177742202 | ||||||||
| FaxNumber: | 7177742634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2009 | ||||||||
| LastUpdateDate: | 04/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | CINCOTTA | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7177610208 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084S0012X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 2084N0400X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1007580840015 | 05 | PA | MEDICAID |