=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811191208
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUBOIS REGIONAL MEDICAL GROUP PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 07/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1049 N FRONT ST
-----------------------------------------------------
City | PHILIPSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16866-8258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-768-8888
-----------------------------------------------------
Fax | 814-768-9444
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 E MAIN ST
-----------------------------------------------------
City | REYNOLDSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15851-1282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-653-8162
-----------------------------------------------------
Fax | 814-653-8164
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP & CFO
-----------------------------------------------------
Name | JOHN SUTIKA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 814-375-6104
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------