Basic Information
Provider Information | |||||||||
NPI: | 1710469754 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. LUKE'S WARREN PHYSICIAN GROUP, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
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: | 187 COUNTY ROAD 519 STE 1 | ||||||||
Address2: |   | ||||||||
City: | BELVIDERE | ||||||||
State: | NJ | ||||||||
PostalCode: | 078231900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9088473418 | ||||||||
FaxNumber: | 9088473419 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2018 | ||||||||
LastUpdateDate: | 07/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THOMAS | ||||||||
AuthorizedOfficialFirstName: | JAMIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9088476702 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DO | ||||||||
NPICertificationDate: | 07/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.