Provider Demographics
NPI:1801162631
Name:ST. LUKE'S WARREN PHYSICIAN GROUP, PC
Entity type:Organization
Organization Name:ST. LUKE'S WARREN PHYSICIAN GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-847-2621
Mailing Address - Street 1:755 MEMORIAL PKWY BLDG SUITE201
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-2748
Mailing Address - Country:US
Mailing Address - Phone:908-847-8884
Mailing Address - Fax:833-204-9604
Practice Address - Street 1:755 MEMORIAL PKWY
Practice Address - Street 2:BLDG 200, SUITE 201
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-2748
Practice Address - Country:US
Practice Address - Phone:908-859-8884
Practice Address - Fax:908-859-6841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7123604Medicaid
NJ7123604Medicaid