Provider Demographics
NPI:1407415987
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 1:1000 DUTCH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-9727
Mailing Address - Country:US
Mailing Address - Phone:724-773-4776
Mailing Address - Fax:724-773-4726
Practice Address - Street 1:79 WAGNER ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:MONACA
Practice Address - State:PA
Practice Address - Zip Code:15061-2338
Practice Address - Country:US
Practice Address - Phone:878-439-3598
Practice Address - Fax:878-439-3599
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE VALLEYMEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00156544Medicaid