Provider Demographics
NPI:1225280829
Name:HERITAGE VALLEY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:HERITAGE VALLEY MEDICAL GROUP, INC.
Other - Org Name:HVMG VEIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
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 1:605 SHARON RD
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-1919
Mailing Address - Country:US
Mailing Address - Phone:888-844-8346
Mailing Address - Fax:
Practice Address - Street 1:605 SHARON RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-1919
Practice Address - Country:US
Practice Address - Phone:888-844-8346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015654460023Medicaid
OH0202677Medicaid
OH9280531Medicare PIN
PA0015654460023Medicaid