Provider Demographics
NPI:1326492257
Name:ST. LUKE'S PHYSICIAN GROUP INC
Entity Type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP INC
Other - Org Name:ST. LUKE'S FOGELSVILLE PRIMARY CARE
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:484-526-4911
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:610-336-4676
Mailing Address - Fax:833-821-0341
Practice Address - Street 1:1251 TURNSTONE DRIVE
Practice Address - Street 2:SUITE 120
Practice Address - City:FOGELSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18051-1713
Practice Address - Country:US
Practice Address - Phone:484-822-5150
Practice Address - Fax:484-822-5160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA686024OtherMEDICARE GROUP