1770741456 NPI number — DUBOIS REGIONAL MEDICAL GROUP, PC

Table of content: (NPI 1770741456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770741456 NPI number — DUBOIS REGIONAL MEDICAL GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUBOIS REGIONAL MEDICAL GROUP, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DRMG CLEARFIELD CENTER FOR CHILDREN'S CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770741456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 HOSPITAL AVE
Provider Second Line Business Mailing Address:
BILLING DEPARTMENT
Provider Business Mailing Address City Name:
DU BOIS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15801-1440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-375-6566
Provider Business Mailing Address Fax Number:
814-375-2848

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1033 TURNPIKE AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CLEARFIELD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16830-3061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-768-7618
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SUTIKA
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
AUTHORIZED OFFICIAL & SECRETARY
Authorized Official Telephone Number:
814-375-3385

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 002158632 . This is a "HIGHMARK ASSIGNMENT ACCOUNT" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 100751931 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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