Basic Information
| Provider Information | |||||||||
| NPI: | 1184728727 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DUBOIS REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PENN HIGHLANDS NEUROSURGERY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143712200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 145 HOSPITAL AVE STE 106 | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8145034433 | ||||||||
| FaxNumber: | 8145034435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLINE | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 8143756377 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN HIGHLANDS HEALTHCARE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001675498 | 01 | PA | HIGHMARK BLUE CROSS | OTHER | 1007740880070 | 05 | PA | MEDICAID |