Provider Demographics
NPI:1063463701
Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Entity Type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Other - Org Name:BUSHKILL FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIAVAROLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-526-3569
Mailing Address - Street 1:801 OSTRUM ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1000
Mailing Address - Country:US
Mailing Address - Phone:610-863-7020
Mailing Address - Fax:866-833-9399
Practice Address - Street 1:497 BUSHKILL PLAZA LN
Practice Address - Street 2:
Practice Address - City:WIND GAP
Practice Address - State:PA
Practice Address - Zip Code:18091-9665
Practice Address - Country:US
Practice Address - Phone:610-863-7020
Practice Address - Fax:866-833-9399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007307530018Medicaid
PA1007307530018Medicaid