Provider Demographics
NPI:1720371925
Name:HERITAGE VALLEY MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:HERITAGE VALLEY MEDICAL GROUP, INC
Other - Org Name:HERITAGE VALLEY PULMONARY SEWICKLEY
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 1:720 BLACKBURN RD
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143-1459
Mailing Address - Country:US
Mailing Address - Phone:412-749-7537
Mailing Address - Fax:412-749-7354
Practice Address - Street 1:720 BLACKBURN RD
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143-1459
Practice Address - Country:US
Practice Address - Phone:412-749-7537
Practice Address - Fax:412-749-7354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-20
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049161L207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014950830029Medicaid
PA078347Medicare PIN