Provider Demographics
NPI:1003477720
Name:HERITAGE VALLEY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:HERITAGE VALLEY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT & CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-749-7027
Mailing Address - Street 1:596 PINE HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MC KEES ROCKS
Mailing Address - State:PA
Mailing Address - Zip Code:15136-1661
Mailing Address - Country:US
Mailing Address - Phone:412-771-6003
Mailing Address - Fax:412-771-3575
Practice Address - Street 1:596 PINE HOLLOW RD
Practice Address - Street 2:
Practice Address - City:MC KEES ROCKS
Practice Address - State:PA
Practice Address - Zip Code:15136-1661
Practice Address - Country:US
Practice Address - Phone:412-771-6003
Practice Address - Fax:412-771-3575
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE VALLEY MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001565446Medicaid