Basic Information
| Provider Information | |||||||||
| NPI: | 1538601802 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. LUKE'S WARREN PHYSICIAN GROUP, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 755 MEMORIAL PKWY STE 105 | ||||||||
| Address2: | |||||||||
| City: | PHILLIPSBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088652774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845262200 | ||||||||
| FaxNumber: | 8666917526 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 MEMORIAL PKWY | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | PHILLIPSBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088652748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845262200 | ||||||||
| FaxNumber: | 4845262220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2016 | ||||||||
| LastUpdateDate: | 02/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | DELMONICO | ||||||||
| AuthorizedOfficialFirstName: | GERARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9088596765 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7123604 | 05 | NJ | MEDICAID | 054621 | 01 | NJ | MEDICARE | OTHER |