Provider Demographics
NPI:1588043376
Name:ST. LUKE'S PHYSICIAN GROUP INC.
Entity Type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP INC.
Other - Org Name:ASC AT ST. LUKE'S HOSPITAL
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 1:100 N 3RD ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18042-1869
Mailing Address - Country:US
Mailing Address - Phone:484-503-8010
Mailing Address - Fax:484-503-8009
Practice Address - Street 1:100 N 3RD ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18042-1869
Practice Address - Country:US
Practice Address - Phone:484-503-8010
Practice Address - Fax:484-503-8009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA686024Medicare PIN