Provider Demographics
NPI:1770741456
Name:DUBOIS REGIONAL MEDICAL GROUP, PC
Entity type:Organization
Organization Name:DUBOIS REGIONAL MEDICAL GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL & SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SUTIKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-375-3385
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:BILLING DEPARTMENT
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-375-6566
Mailing Address - Fax:814-375-2848
Practice Address - Street 1:1033 TURNPIKE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CLEARFIELD
Practice Address - State:PA
Practice Address - Zip Code:16830-3061
Practice Address - Country:US
Practice Address - Phone:814-768-7618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN HIGHLANDS HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-29
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363L00000X, 363A00000X, 208000000X, 261QH0100X, 261QH0100X
PAOA000927363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA002158632OtherHIGHMARK ASSIGNMENT ACCOUNT
PA100751931Medicaid
PA1007740880070Medicaid
PA002158632OtherHIGHMARK ASSIGNMENT ACCOUNT