Healthcare Provider Details

I. General information

NPI: 1972931863
Provider Name (Legal Business Name): HERITAGE VALLEY MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2013
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 DUTCH RIDGE RD
BEAVER PA
15009-9727
US

IV. Provider business mailing address

1000 DUTCH RIDGE RD
BEAVER PA
15009-9727
US

V. Phone/Fax

Practice location:
  • Phone: 724-773-1941
  • Fax:
Mailing address:
  • Phone: 724-773-1941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA055292
License Number StatePA

VIII. Authorized Official

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