Basic Information
| Provider Information | |||||||||
| NPI: | 1144785833 | ||||||||
| 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: | 185 ROSEBERRY ST | ||||||||
| Address2: | FARLEY BLDG., 2ND FLOOR | ||||||||
| City: | PHILLIPSBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088472621 | ||||||||
| FaxNumber: | 9088473045 | ||||||||
| Practice Location | |||||||||
| Address1: | 185 ROSEBERRY ST | ||||||||
| Address2: | EMERGENCY DEPT | ||||||||
| City: | PHILLIPSBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845264789 | ||||||||
| FaxNumber: | 4845266676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2019 | ||||||||
| LastUpdateDate: | 02/06/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT MEDICAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 4845264805 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.