Basic Information
| Provider Information | |||||||||
| NPI: | 1295009918 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. LUKE'S WARREN PHYSICIAN GROUP, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 STATE ROUTE 31 S | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078824069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088473100 | ||||||||
| FaxNumber: | 8662769292 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 STATE ROUTE 31 S | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078824069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9086890777 | ||||||||
| FaxNumber: | 9088353037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2012 | ||||||||
| LastUpdateDate: | 01/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | DELMONICO | ||||||||
| AuthorizedOfficialFirstName: | GERARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9088596568 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0029921 | 05 | NJ | MEDICAID |