Provider Demographics
NPI:1871745455
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 1:1101 5TH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CORAOPOLIS
Mailing Address - State:PA
Mailing Address - Zip Code:15108-1577
Mailing Address - Country:US
Mailing Address - Phone:412-269-0899
Mailing Address - Fax:412-269-1462
Practice Address - Street 1:1101 5TH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CORAOPOLIS
Practice Address - State:PA
Practice Address - Zip Code:15108-1577
Practice Address - Country:US
Practice Address - Phone:412-269-0899
Practice Address - Fax:412-269-1462
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
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014950830029Medicaid
OH2297465Medicaid
PA078347Medicare PIN