Provider Demographics
NPI:1982754198
Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Entity Type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Other - Org Name:CONNELLY 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 1:623 E BROAD ST
Mailing Address - Street 2:2ND FLR
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-6332
Mailing Address - Country:US
Mailing Address - Phone:610-954-6048
Mailing Address - Fax:610-954-3189
Practice Address - Street 1:501 N 17TH ST
Practice Address - Street 2:ST 108
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-5044
Practice Address - Country:US
Practice Address - Phone:610-494-4760
Practice Address - Fax:610-820-9122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA023958Medicare ID - Type UnspecifiedMEDICARE