Basic Information
Provider Information | |||||||||
NPI: | 1710296157 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DUBOIS REGIONAL MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PENN HIGHLANDS INTEGRATED RECOVERY CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 HOSPITAL AVENUE | ||||||||
Address2: |   | ||||||||
City: | DU BOIS | ||||||||
State: | PA | ||||||||
PostalCode: | 158011440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8143754200 | ||||||||
FaxNumber: | 8143724230 | ||||||||
Practice Location | |||||||||
Address1: | 635 MAPLE AVE | ||||||||
Address2: |   | ||||||||
City: | DU BOIS | ||||||||
State: | PA | ||||||||
PostalCode: | 15801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8143758055 | ||||||||
FaxNumber: | 8143758056 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2010 | ||||||||
LastUpdateDate: | 08/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHNEIDER | ||||||||
AuthorizedOfficialFirstName: | HEATHER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP & CFO | ||||||||
AuthorizedOfficialTelephone: | 8143756432 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PENN HIGHLANDS HEALTHCARE | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207QA0401X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
ID | Type | State | Issuer | Description | 1007740880070 | 05 | PA |   | MEDICAID |