Healthcare Provider Details

I. General information

NPI: 1396216727
Provider Name (Legal Business Name): HERITAGE VALLEY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 3RD ST
BEAVER PA
15009-2333
US

IV. Provider business mailing address

1000 DUTCH RIDGE RD OFC
BEAVER PA
15009-9727
US

V. Phone/Fax

Practice location:
  • Phone: 724-775-2112
  • Fax:
Mailing address:
  • Phone: 724-773-4776
  • Fax: 724-773-4726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: NORMAN F MITRY
Title or Position: PRESIDENT & CEO
Credential:
Phone: 724-773-4776