Provider Demographics
NPI:1700984622
Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Entity Type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Other - Org Name:SOUTH MOUNTAIN 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 1:1545 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-3901
Mailing Address - Country:US
Mailing Address - Phone:610-865-6112
Mailing Address - Fax:610-865-3307
Practice Address - Street 1:1545 BROADWAY
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-3901
Practice Address - Country:US
Practice Address - Phone:610-865-6112
Practice Address - Fax:610-865-3307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207Q00000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No310400000XNursing & Custodial Care FacilitiesAssisted Living FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA812708Medicare PIN