Healthcare Provider Details

I. General information

NPI: 1558868570
Provider Name (Legal Business Name): PENN HIGHLANDS LIFE'S JOURNEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 W PARK AVE
DU BOIS PA
15801-2277
US

IV. Provider business mailing address

100 HOSPITAL AVE
DU BOIS PA
15801-1440
US

V. Phone/Fax

Practice location:
  • Phone: 814-371-1900
  • Fax: 814-503-8568
Mailing address:
  • Phone: 814-375-4024
  • Fax: 814-372-2579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: RUSSELL CAMERON
Title or Position: DIRECTOR, AUTHORIZED OFFICIAL
Credential: MD
Phone: 814-375-3442