Provider Demographics
NPI:1093190902
Name:DUBOIS REGIONAL MEDICAL CENTER - PENN HIGHLANDS FAMILY MED EMPORIUM
Entity Type:Organization
Organization Name:DUBOIS REGIONAL MEDICAL CENTER - PENN HIGHLANDS FAMILY MED EMPORIUM
Other - Org Name:PENN HIGHLANDS DUBOIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-788-8580
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 E 4TH ST
Practice Address - Street 2:
Practice Address - City:EMPORIUM
Practice Address - State:PA
Practice Address - Zip Code:15834-1411
Practice Address - Country:US
Practice Address - Phone:814-788-8580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN HIGHLANDS HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100774088Medicaid
PA100774088Medicaid