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	207R00000X	Internal 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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922250778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE VALLEY MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	48462 BELL SCHOOL RD
Second Line	:	SUITE A
City	:	EAST LIVERPOOL
State	:	OH
Zip	:	43920-9625
Country	:	US
Telephone Number	:	330-385-9492
Fax Number	:

Provider Business Practice Location Address
First Line	:	48462 BELL SCHOOL RD
Second Line	:	SUITE A
City	:	EAST LIVERPOOL
State	:	OH
Zip	:	43920-9625
Country	:	US
Telephone Number	:	330-385-9492
Fax Number	:

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

Provider Enumeration Date	:	10/10/2008
Last Update Date	:	06/29/2012

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