Basic Information
| Provider Information | |||||||||
| NPI: | 1538314638 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. LUKE'S PHYSICIAN GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. LUKE'S PLASTIC & RECONSTRUCTIVE SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 74 W BROAD ST STE 170 | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180185738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845265277 | ||||||||
| FaxNumber: | 8338167511 | ||||||||
| Practice Location | |||||||||
| Address1: | 74 W BROAD ST STE 170 | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845265277 | ||||||||
| FaxNumber: | 8338167511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2008 | ||||||||
| LastUpdateDate: | 05/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4845264991 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
No ID Information.