Basic Information
| Provider Information | |||||||||
| NPI: | 1023346673 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DUBOIS REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PENN HIGHLANDS INTERNAL MED ELK/FAMILY MED ELK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147885660 | ||||||||
| FaxNumber: | 8147885663 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 HOSPITAL ST | ||||||||
| Address2: | |||||||||
| City: | RIDGWAY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158531948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147885660 | ||||||||
| FaxNumber: | 8147885663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2009 | ||||||||
| LastUpdateDate: | 10/20/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLINE | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8143756377 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN HIGHLANDS HEALTHCARE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 106218 | 01 | PA | MEDICARE PTAN | OTHER | 089128 | 01 | PA | MEDICARE PTAN | OTHER | 1007740880070 | 05 | PA | MEDICAID |