Basic Information
| Provider Information | |||||||||
| NPI: | 1760786834 | ||||||||
| 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: | 8143756560 | ||||||||
| FaxNumber: | 8143722848 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 MIDWAY DRIVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158013857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143711771 | ||||||||
| FaxNumber: | 8143714417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2011 | ||||||||
| LastUpdateDate: | 03/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | SUTIKA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8143753385 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN HIGHLANDS DUBOIS | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100751931-0013 | 05 | PA | MEDICAID | 002564699 | 01 | PA | HIGHMARK ASSIGNMENT ACCOUNT | OTHER |