Provider Demographics
NPI:1477657195
Name:DUBOIS REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:DUBOIS REGIONAL MEDICAL CENTER
Other - Org Name:PENN HIGHLANDS UROLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position: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:814-375-9200
Mailing Address - Fax:814-375-9980
Practice Address - Street 1:145 HOSPITAL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1462
Practice Address - Country:US
Practice Address - Phone:814-375-9200
Practice Address - Fax:814-375-9980
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN HIGHLANDS HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-12
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001672897OtherHIGHMARK BLUE CROSS
PA089138Medicare ID - Type Unspecified