Basic Information
| Provider Information | |||||||||
| NPI: | 1396216727 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERITAGE VALLEY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 DUTCH RIDGE RD OFC | ||||||||
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| City: | BEAVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150099727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247734776 | ||||||||
| FaxNumber: | 7247734726 | ||||||||
| Practice Location | |||||||||
| Address1: | 274 3RD ST | ||||||||
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| City: | BEAVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150092333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247752112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2018 | ||||||||
| LastUpdateDate: | 12/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | MITRY | ||||||||
| AuthorizedOfficialFirstName: | NORMAN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7247734776 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HERITAGE VALLEY MEDICAL GROUP, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0015654460023 | 05 | PA | MEDICAID |