Provider Demographics
NPI:1124034517
Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Entity Type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Other - Org Name:ST. LUKE'S CENTER FOR PELVIC HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-954-3383
Mailing Address - Street 1:701 OSTRUM ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1155
Mailing Address - Country:US
Mailing Address - Phone:610-954-4960
Mailing Address - Fax:610-954-3162
Practice Address - Street 1:701 OSTRUM ST
Practice Address - Street 2:SUITE 102
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-1155
Practice Address - Country:US
Practice Address - Phone:610-954-4960
Practice Address - Fax:610-954-3162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007307530190Medicaid
PA1007307530190Medicaid