Provider Demographics
NPI:1952586927
Name:HERITAGE VALLEY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:HERITAGE VALLEY MEDICAL GROUP, INC.
Other - Org Name:TRI STATE MEDICAL GROUP, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT AND 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 1:2 PEARTREE WAY
Mailing Address - Street 2:TRI-STATE MEDICAL GROUP INC
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009
Mailing Address - Country:US
Mailing Address - Phone:724-728-4171
Mailing Address - Fax:724-728-2019
Practice Address - Street 1:1200 SHARON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-3148
Practice Address - Country:US
Practice Address - Phone:724-774-5030
Practice Address - Fax:724-774-5040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA020430291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory