Basic Information
| Provider Information | |||||||||
| NPI: | 1326061581 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. LUKE'S PHYSICIAN GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 OSTRUM ST | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180151000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845262400 | ||||||||
| FaxNumber: | 4845263697 | ||||||||
| Practice Location | |||||||||
| Address1: | 257 BRODHEAD RD | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180178938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848225700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | CHIAVAROLI | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4845263569 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 261QM0801X | 920240 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1007307530002 | 05 | PA | MEDICAID |