Basic Information
Provider Information | |||||||||
NPI: | 1619618030 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. LUKE'S WARREN PHYSICIAN GROUP, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST. LUKE'S CENTER FOR UROLOGY WARREN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 185 ROSEBERRY ST | ||||||||
Address2: | FARLEY BLDG., 2ND FLOOR | ||||||||
City: | PHILLIPSBURG | ||||||||
State: | NJ | ||||||||
PostalCode: | 08865 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9088472621 | ||||||||
FaxNumber: | 9088473045 | ||||||||
Practice Location | |||||||||
Address1: | 755 MEMORIAL PKWY STE 302 | ||||||||
Address2: |   | ||||||||
City: | PHILLIPSBURG | ||||||||
State: | NJ | ||||||||
PostalCode: | 088652771 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4845262598 | ||||||||
FaxNumber: | 8665224710 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2022 | ||||||||
LastUpdateDate: | 04/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHIAVAROLI | ||||||||
AuthorizedOfficialFirstName: | SUE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4845263569 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
No ID Information.