1407415987 NPI number — HERITAGE VALLEY MEDICAL GROUP, INC.

Table of content: (NPI 1407415987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407415987 NPI number — HERITAGE VALLEY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE VALLEY MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407415987
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 DUTCH RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15009-9727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-773-4776
Provider Business Mailing Address Fax Number:
724-773-4726

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
79 WAGNER ROAD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
MONACA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15061-2338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
878-439-3598
Provider Business Practice Location Address Fax Number:
878-439-3599
Provider Enumeration Date:
06/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
RANDALL
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
VICE PRESIDENT & CFO
Authorized Official Telephone Number:
412-749-7027

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00156544 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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