Basic Information
| Provider Information | |||||||||
| NPI: | 1730498452 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DUBOIS REGIONAL MEDICAL GROUP, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DRMG ACUTE CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143756560 | ||||||||
| FaxNumber: | 8143722848 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 INDUSTRIAL DR | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158013842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143756072 | ||||||||
| FaxNumber: | 8145038750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2010 | ||||||||
| LastUpdateDate: | 03/12/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SUTIKA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 8143753385 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN HIGHLANDS HEALTHCARE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261Q00000X | PA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 100751931-0012 | 05 | PA | MEDICAID | 2525565 | 01 | PA | HIGHMARK | OTHER |