Basic Information
Provider Information | |||||||||
NPI: | 1679972376 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. LUKE'S PHYSICIAN GROUP, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1803 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | STROUDSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 183601027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5704210170 | ||||||||
FaxNumber: | 5704245167 | ||||||||
Practice Location | |||||||||
Address1: | 1581 N 9TH ST | ||||||||
Address2: |   | ||||||||
City: | STROUDSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 183607576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2722124490 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2014 | ||||||||
LastUpdateDate: | 07/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHIAVAROLI | ||||||||
AuthorizedOfficialFirstName: | SUE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CVO SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 4845263569 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.