=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154962561
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERITAGE VALLEY MULTISPECIALTY GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2019
-----------------------------------------------------
Last Update Date | 10/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6521 STEUBENVILLE PIKE
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15205-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-773-5890
-----------------------------------------------------
Fax | 724-773-5892
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6521 STEUBENVILLE PIKE
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15205-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-773-5890
-----------------------------------------------------
Fax | 724-773-5892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT & CEO
-----------------------------------------------------
Name | BRYAN J RANDALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 412-749-7027
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------