Provider Demographics
NPI:1174864490
Name:ST. LUKE'S WARREN PHYSICIAN GROUP, PC
Entity Type:Organization
Organization Name:ST. LUKE'S WARREN PHYSICIAN GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
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 1:755 MEMORIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-2748
Mailing Address - Country:US
Mailing Address - Phone:484-526-7555
Mailing Address - Fax:866-281-9054
Practice Address - Street 1:123A ROSEBERRY ST
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-1629
Practice Address - Country:US
Practice Address - Phone:484-526-7555
Practice Address - Fax:866-281-9054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-12
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0678198Medicaid
NJ054771Medicare PIN