Healthcare Provider Details

I. General information

NPI: 1609242569
Provider Name (Legal Business Name): DUBOIS REG MED CTR - PENN HIGHLANDS DUBOIS Q-CARE/FAMILY MED RIDGEWAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2015
Last Update Date: 02/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 METOXET ST
RIDGWAY PA
15853-1932
US

IV. Provider business mailing address

100 HOSPITAL AVE
DU BOIS PA
15801-1440
US

V. Phone/Fax

Practice location:
  • Phone: 814-371-2200
  • Fax:
Mailing address:
  • Phone: 814-371-2200
  • Fax: 814-375-4232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN S KLINE
Title or Position: VP/CFO
Credential:
Phone: 814-375-6377