Basic Information
| Provider Information | |||||||||
| NPI: | 1639373020 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DUBOIS REGIONAL MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143756566 | ||||||||
| FaxNumber: | 8143722848 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 TURNPIKE AVE | ||||||||
| Address2: | |||||||||
| City: | CLEARFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168301233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147652412 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | SUTIKA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL & SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 8143753385 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN HIGHLANDS HEALTHCARE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100751931 | 05 | PA | MEDICAID |