Provider Demographics
NPI:1801386024
Name:DUBOIS REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:DUBOIS REGIONAL MEDICAL CENTER
Other - Org Name:PENN HIGHLANDS DUBOIS SUMMIT ST BLDG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/CFO/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
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:814-375-6560
Mailing Address - Fax:814-372-2848
Practice Address - Street 1:111 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-1422
Practice Address - Country:US
Practice Address - Phone:814-849-1480
Practice Address - Fax:814-849-1481
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN HIGHLANDS HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal 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
PA1007740880070Medicaid
PA106218OtherGROUP MC