Basic Information
| Provider Information | |||||||||
| NPI: | 1407415987 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERITAGE VALLEY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 DUTCH RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BEAVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150099727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247734776 | ||||||||
| FaxNumber: | 7247734726 | ||||||||
| Practice Location | |||||||||
| Address1: | 79 WAGNER ROAD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MONACA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150612338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8784393598 | ||||||||
| FaxNumber: | 8784393599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2019 | ||||||||
| LastUpdateDate: | 06/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | RANDALL | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 4127497027 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HERITAGE VALLEYMEDICAL GROUP, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00156544 | 05 | PA | MEDICAID |