Provider Demographics
| NPI: | 1861868143 |
|---|---|
| Name: | DUBOIS REGIONAL MEDICAL CENTER - PENN HIGHLANDS DUBOIS MEDICAL ARTS |
| Entity type: | Organization |
| Organization Name: | DUBOIS REGIONAL MEDICAL CENTER - PENN HIGHLANDS DUBOIS MEDICAL ARTS |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| 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: | 814-371-2200 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 145 HOSPITAL AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | DU BOIS |
| Practice Address - State: | PA |
| Practice Address - Zip Code: | 15801-1462 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 814-371-2200 |
| Practice Address - Fax: | 814-372-4232 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | PENN HIGHLANDS HEALTHCARE |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2015-08-20 |
| Last Update Date: | 2017-04-04 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 2084B0040X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Behavioral Neurology & Neuropsychiatry | Group - Multi-Specialty |
| No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
| No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
| No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
| No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | Group - Multi-Specialty |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 207QS0010X | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| PA | 1007740880070 | Medicaid | |
| PA | 390086 | Medicare PIN |
