Provider Demographics
NPI:1245283811
Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Entity type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Other - Org Name:<UNAVAIL>
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 1:701 OSTRUM STREET
Mailing Address - Street 2:SUITE 603
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1184
Mailing Address - Country:US
Mailing Address - Phone:484-526-3990
Mailing Address - Fax:610-868-2915
Practice Address - Street 1:701 OSTRUM STREET
Practice Address - Street 2:SUITE 603
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1153
Practice Address - Country:US
Practice Address - Phone:484-526-3990
Practice Address - Fax:610-868-2915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD046699L208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007307530136Medicaid
PA071812Medicare ID - Type Unspecified