Healthcare Provider Details

I. General information

NPI: 1508972175
Provider Name (Legal Business Name): HERITAGE MEDICAL GROUP, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

362 N BROADWAY FL 2
SLEEPY HOLLOW NY
10591-2310
US

IV. Provider business mailing address

362 N BROADWAY FL 2
SLEEPY HOLLOW NY
10591-2310
US

V. Phone/Fax

Practice location:
  • Phone: 914-631-2070
  • Fax: 914-631-0797
Mailing address:
  • Phone: 914-631-2070
  • Fax: 914-631-0797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE O'DONNELL
Title or Position: PRACTICE MANAGER
Credential:
Phone: 914-631-2070