Provider Demographics
NPI:1851698468
Name:ST. LUKE'S PHYSICIAN GROUP, INC
Entity Type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP, INC
Other - Org Name:ST. LUKE'S INTERNAL MEDICINE MINERS
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:610-954-4911
Mailing Address - Street 1:360 W RUDDLE ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:COALDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18218-1027
Mailing Address - Country:US
Mailing Address - Phone:570-645-1499
Mailing Address - Fax:
Practice Address - Street 1:360 W RUDDLE ST
Practice Address - Street 2:SUITE 800
Practice Address - City:COALDALE
Practice Address - State:PA
Practice Address - Zip Code:18218-1027
Practice Address - Country:US
Practice Address - Phone:570-645-1499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty