Provider Demographics
NPI:1356593933
Name:HERITAGE VALLEY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:HERITAGE VALLEY MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:111 HAZEL LANE, SUITE 100
Mailing Address - Street 2:EDGEWORTH SQUARE
Mailing Address - City:SEWICKELY
Mailing Address - State:PA
Mailing Address - Zip Code:15143
Mailing Address - Country:US
Mailing Address - Phone:412-741-8862
Mailing Address - Fax:
Practice Address - Street 1:111 HAZEL LANE, SUITE 100
Practice Address - Street 2:EDGEWORTH SQUARE
Practice Address - City:SEWICKELY
Practice Address - State:PA
Practice Address - Zip Code:15143
Practice Address - Country:US
Practice Address - Phone:412-741-8862
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
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014950830029Medicaid
OH2297465Medicaid
PA0014950830029Medicaid