Provider Demographics
NPI:1487943809
Name:DUBOIS REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:DUBOIS REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SUTIKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-375-3385
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:BILLING DEPARTMENT
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-375-3033
Mailing Address - Fax:814-372-2613
Practice Address - Street 1:100 HOSPITAL AVE
Practice Address - Street 2:BILLING DEPARTMENT
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1440
Practice Address - Country:US
Practice Address - Phone:814-375-3033
Practice Address - Fax:814-372-2613
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN HIGHLANDS HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-06
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 261QH0100X, 261QH0100X
PAOS005055L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
002627757OtherHIGHMARK ASSIGNMENT ACCOUNT
PA1007740880070Medicaid
PA1007740880076Medicaid
PA1007740880076Medicaid