Basic Information
| Provider Information | |||||||||
| NPI: | 1861556706 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. LUKE'S PHYSICIAN GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FOUNTAIN HILL MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 OSTRUM ST | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180151000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109543383 | ||||||||
| FaxNumber: | 6109546500 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | QUAKERTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189511573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155384713 | ||||||||
| FaxNumber: | 2155384704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6109543383 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1007307530170 | 05 | PA | MEDICAID |