Basic Information
Provider Information | |||||||||
NPI: | 1992298160 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DUBOIS REGIONAL MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PENN HIGHLANDS FAMILY MEDICINE CONTINUITY CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 HOSPITAL AVE | ||||||||
Address2: |   | ||||||||
City: | DU BOIS | ||||||||
State: | PA | ||||||||
PostalCode: | 158011440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8143754200 | ||||||||
FaxNumber: | 8143754217 | ||||||||
Practice Location | |||||||||
Address1: | 145 HOSPITAL AVE STE 315 | ||||||||
Address2: |   | ||||||||
City: | DU BOIS | ||||||||
State: | PA | ||||||||
PostalCode: | 15801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8145034305 | ||||||||
FaxNumber: | 8145034307 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2018 | ||||||||
LastUpdateDate: | 06/19/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KLINE | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | VP/CFO, AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 8143756377 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PENN HIGHLANDS HEALTHCARE | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 106218 | 01 | PA | MC | OTHER | 1007740880070 | 05 | PA |   | MEDICAID |