Provider Demographics
NPI:1659467199
Name:DUBOIS REGIONAL MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:DUBOIS REGIONAL MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SUTIKA
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:814-375-3385
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:814-375-6560
Mailing Address - Fax:814-372-2848
Practice Address - Street 1:123 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DUBOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2428
Practice Address - Country:US
Practice Address - Phone:814-371-1510
Practice Address - Fax:814-371-2922
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN HIGHLANDS DUBOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-04
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - 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
PA001358073OtherHIGHMARK ASSIGNMENT ACCOUNT
PA1007519310001Medicaid
PA1007519310007Medicaid
PA1007519310001Medicaid