=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689621401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERITAGE VALLEY PEDIATRICS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 COLLEGE AVE
-----------------------------------------------------
City | BEAVER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15009-2706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-774-4070
-----------------------------------------------------
Fax | 724-774-2872
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 PEARTREE WAY
-----------------------------------------------------
City | BEAVER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15009-1954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-773-6802
-----------------------------------------------------
Fax | 724-770-7919
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AND CEO
-----------------------------------------------------
Name | MR. NORMAN F MITRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 724-773-4779
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------