Provider Demographics
NPI:1134487119
Name:ST LUKE'S PHYSICIAN GROUP INC
Entity Type:Organization
Organization Name:ST LUKE'S PHYSICIAN GROUP INC
Other - Org Name:ST. LUKE'S ASHLAND FAMILY PRACTICE
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:484-526-4991
Mailing Address - Street 1:530 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17921-1330
Mailing Address - Country:US
Mailing Address - Phone:570-889-3103
Mailing Address - Fax:866-230-8090
Practice Address - Street 1:530 CENTRE ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:PA
Practice Address - Zip Code:17921-1330
Practice Address - Country:US
Practice Address - Phone:570-889-3103
Practice Address - Fax:866-230-8090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
PA207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA686024Medicare PIN