Provider Demographics
NPI:1386008720
Name:DUBOIS REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:DUBOIS REGIONAL MEDICAL CENTER
Other - Org Name:PENN HIGHLANDS DUBOIS FAMILY MEDICINE BOWSER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL, VP & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:KLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-375-6377
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:814-375-4217
Mailing Address - Fax:814-375-4232
Practice Address - Street 1:416 N BROAD ST
Practice Address - Street 2:
Practice Address - City:EMPORIUM
Practice Address - State:PA
Practice Address - Zip Code:15834-1402
Practice Address - Country:US
Practice Address - Phone:814-486-2202
Practice Address - Fax:814-788-4616
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN HIGHLANDS HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100774088Medicaid
PA100774088Medicaid