Basic Information
| Provider Information | |||||||||
| NPI: | 1982054490 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERITAGE VALLEY MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | HVMG MOUHANNAD AZZOUZ, MD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 DUTCH RIDGE RD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | BEAVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150099727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247734776 | ||||||||
| FaxNumber: | 7247734726 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 DUTCH RIDGE RD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | BEAVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150099727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247734776 | ||||||||
| FaxNumber: | 7247734726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2016 | ||||||||
| LastUpdateDate: | 06/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | MITRY | ||||||||
| AuthorizedOfficialFirstName: | NORMAN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7247734776 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.