Basic Information
| Provider Information | |||||||||
| NPI: | 1780090811 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DUBOIS REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PENN HIGHLANDS PEDIATRICS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
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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: | 123 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | DUBOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143711510 | ||||||||
| FaxNumber: | 8143712922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2014 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHNEIDER | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
| AuthorizedOfficialMiddleName: | BOLLINGER | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 8143756432 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN HIGHLANDS HEALTHCARE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/09/2022 | ||||||||
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 | 1007740880070 | 05 | PA | MEDICAID | 3069153 | 01 | PA | HIGHMARK ASSIGNMENT ACCOUNT | OTHER |