Basic Information
Provider Information | |||||||||
NPI: | 1043635733 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. LUKE'S WARREN PHYSICIAN GROUP, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 27957 | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841270957 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9088351910 | ||||||||
FaxNumber: | 9088351924 | ||||||||
Practice Location | |||||||||
Address1: | 123 ROSEBERRY ST | ||||||||
Address2: |   | ||||||||
City: | PHILLIPSBURG | ||||||||
State: | NJ | ||||||||
PostalCode: | 088651629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6108662600 | ||||||||
FaxNumber: | 6108617640 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/04/2014 | ||||||||
LastUpdateDate: | 07/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DELMONICO | ||||||||
AuthorizedOfficialFirstName: | GERARD | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9088596568 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 7123604 | 05 | NJ |   | MEDICAID |