MEDICARE: HERITAGE VALLEY MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255788287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE VALLEY MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	935 THORN RUN RD
Second Line	:	SUITE 201
City	:	MOON TWP
State	:	PA
Zip	:	15108-2861
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	935 THORN RUN RD
Second Line	:	SUITE 201
City	:	MOON TWP
State	:	PA
Zip	:	15108-2861
Country	:	US
Telephone Number	:	724-773-8388
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	MR. NORMAN F MITRY
Credential	:
Telephone Number	:	724-773-4776

Provider Enumeration Date	:	05/19/2016
Last Update Date	:	05/19/2016

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