Basic Information
| Provider Information | |||||||||
| NPI: | 1417518036 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERITAGE VALLEY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 FOSTER AVE STE B | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152052317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122624694 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 FOSTER AVE STE B | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152052317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122624694 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2019 | ||||||||
| LastUpdateDate: | 06/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | RANDALL | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 4127497027 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HERITAGE VALLEY MEDICAL GROUP, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001565446 | 05 | PA | MEDICAID |