Provider Demographics
NPI:1093171183
Name:HERITAGE VALLEY MEDICAL GROUP, ICN
Entity Type:Organization
Organization Name:HERITAGE VALLEY MEDICAL GROUP, ICN
Other - Org Name:HVMG UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MITRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-773-4776
Mailing Address - Street 1:2 PEARTREE WAY
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-1954
Mailing Address - Country:US
Mailing Address - Phone:724-773-6802
Mailing Address - Fax:724-770-7919
Practice Address - Street 1:2 PEARTREE WAY
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-1954
Practice Address - Country:US
Practice Address - Phone:724-773-6802
Practice Address - Fax:724-770-7919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015654460023Medicaid
PA0015654460023Medicaid