Provider Demographics
NPI:1467688358
Name:ST. LUKE'S PHYSICIAN GROUP INC
Entity Type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP INC
Other - Org Name:ROBERT A. MATTA, DO FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-954-4911
Mailing Address - Street 1:1501 LEHIGH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-3880
Mailing Address - Country:US
Mailing Address - Phone:610-435-8643
Mailing Address - Fax:610-435-8270
Practice Address - Street 1:1501 LEHIGH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-3880
Practice Address - Country:US
Practice Address - Phone:610-435-8643
Practice Address - Fax:610-435-8270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA686024Medicare PIN