Provider Demographics
NPI:1750488029
Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Entity Type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Other - Org Name:VALLEY 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:610-954-4991
Mailing Address - Street 1:623 E BROAD ST
Mailing Address - Street 2:2ND FLR
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-6332
Mailing Address - Country:US
Mailing Address - Phone:610-954-6048
Mailing Address - Fax:610-954-3189
Practice Address - Street 1:2319 UNION BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18109-1651
Practice Address - Country:US
Practice Address - Phone:610-435-0816
Practice Address - Fax:610-435-9986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-04-16
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
PA01575451Medicaid
PA184091Medicare ID - Type UnspecifiedMEDICARE