MEDICARE: HERITAGE VALLEY MEDICAL GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site	OS010074L	PA

General Provider Information

NPI Number	:	1881932358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE VALLEY MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	5626 OBERLIN DR
Second Line	:	110
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1705
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6521 STEUBENVILLE PIKE
Second Line	:	A
City	:	PITTSBURGH
State	:	PA
Zip	:	15205-1005
Country	:	US
Telephone Number	:	412-749-6920
Fax Number	:

Authorized Official
Title or Position	:	VP OPS
Name	:	KENNY GREEN
Credential	:
Telephone Number	:	858-964-1506

Provider Enumeration Date	:	01/17/2013
Last Update Date	:	01/17/2013

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