Healthcare Provider Details

I. General information

NPI: 1770741456
Provider Name (Legal Business Name): DUBOIS REGIONAL MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 TURNPIKE AVE SUITE 200
CLEARFIELD PA
16830-3061
US

IV. Provider business mailing address

100 HOSPITAL AVE BILLING DEPARTMENT
DU BOIS PA
15801-1440
US

V. Phone/Fax

Practice location:
  • Phone: 814-768-7618
  • Fax:
Mailing address:
  • Phone: 814-375-6566
  • Fax: 814-375-2848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN S SUTIKA
Title or Position: AUTHORIZED OFFICIAL & SECRETARY
Credential:
Phone: 814-375-3385