Provider Demographics
NPI:1689826281
Name:HERITAGE VALLEY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:HERITAGE VALLEY MEDICAL GROUP, INC.
Other - Org Name:HVMG VALLEY INTERNAL MEDICINE
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 1:500 SHARON RD
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-1957
Mailing Address - Country:US
Mailing Address - Phone:724-728-8751
Mailing Address - Fax:
Practice Address - Street 1:500 SHARON RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-1957
Practice Address - Country:US
Practice Address - Phone:724-728-8751
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
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0202677Medicaid
PA0015654460023Medicaid
OH0202677Medicaid
PA807864Medicare PIN