Provider Demographics
NPI:1760740864
Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Entity Type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Other - Org Name:
Other - Org Type:
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 1:3180 ROUTE 611 STE 22
Mailing Address - Street 2:
Mailing Address - City:BARTONSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18321-7825
Mailing Address - Country:US
Mailing Address - Phone:570-664-8900
Mailing Address - Fax:
Practice Address - Street 1:3180 ROUTE 611
Practice Address - Street 2:SUITE 22
Practice Address - City:BARTONSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18321-7824
Practice Address - Country:US
Practice Address - Phone:570-664-8900
Practice Address - Fax:570-664-8905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-26
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA686024Medicare PIN