Basic Information
Provider Information | |||||||||
NPI: | 1104070531 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HERITAGE MEDICAL GROUP, LLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NEWPORT FAMILY PRACTICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3 WALNUT ST | ||||||||
Address2: | SUITE 206 | ||||||||
City: | LEMOYNE | ||||||||
State: | PA | ||||||||
PostalCode: | 170431168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7177610208 | ||||||||
FaxNumber: | 7177612023 | ||||||||
Practice Location | |||||||||
Address1: | 46 RED HILL CT | ||||||||
Address2: |   | ||||||||
City: | NEWPORT | ||||||||
State: | PA | ||||||||
PostalCode: | 170748706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175673151 | ||||||||
FaxNumber: | 7175677571 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/12/2008 | ||||||||
LastUpdateDate: | 11/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CINCOTTA | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7177610208 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.