Provider Demographics
NPI:1851794549
Name:DUBOIS REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:DUBOIS REGIONAL MEDICAL CENTER
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: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:814-375-6183
Mailing Address - Fax:814-372-2718
Practice Address - Street 1:145 HOSPITAL AVE STE 105
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1463
Practice Address - Country:US
Practice Address - Phone:814-375-3890
Practice Address - Fax:814-375-3893
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN HIGHLANDS HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN002090133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3093208OtherHIGHMARK ASSIGNMENT ACCOUNT