Provider Demographics
NPI:1255817243
Name:MON VALE ORTHOPEDIC GROUP, INC.
Entity type:Organization
Organization Name:MON VALE ORTHOPEDIC GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-379-5802
Mailing Address - Street 1:800 PLAZA DRIVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BELLE VERNON
Mailing Address - State:PA
Mailing Address - Zip Code:15012-4019
Mailing Address - Country:US
Mailing Address - Phone:724-379-5816
Mailing Address - Fax:724-379-5874
Practice Address - Street 1:371 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:PA
Practice Address - Zip Code:15419-1278
Practice Address - Country:US
Practice Address - Phone:724-648-3862
Practice Address - Fax:724-938-3039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011318300010Medicaid
150719OtherHIGHMARK BC BS