Basic Information
| Provider Information | |||||||||
| NPI: | 1285298737 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. LUKE'S PHYSICIAN GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 218A DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | PALMERTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180711813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108266353 | ||||||||
| FaxNumber: | 6108266359 | ||||||||
| Practice Location | |||||||||
| Address1: | 218A DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | PALMERTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180711813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108266353 | ||||||||
| FaxNumber: | 6108266359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2019 | ||||||||
| LastUpdateDate: | 04/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4845264999 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. LUKE'S PHYSICIAN GROUP, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.