Basic Information
| Provider Information | |||||||||
| NPI: | 1851731012 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DUBOIS REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PENN HIGHLANDS DUBOIS CRICKLEWOOD BLDG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143756560 | ||||||||
| FaxNumber: | 8143752848 | ||||||||
| Practice Location | |||||||||
| Address1: | 1008 S 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | CLARION | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143753770 | ||||||||
| FaxNumber: | 8143753772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2013 | ||||||||
| LastUpdateDate: | 07/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | KLINE | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 8143756377 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN HIGHLANDS HEALTHCARE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | PA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RE0101X | PA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RP1001X | PA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | PA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207W00000X | PA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 207R00000X | PA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1007740880070 | 05 | PA | MEDICAID |