1124034517 NPI number — ST. LUKE'S PHYSICIAN GROUP, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124034517 NPI number — ST. LUKE'S PHYSICIAN GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. LUKE'S PHYSICIAN GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ST. LUKE'S CENTER FOR PELVIC HEALTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124034517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 OSTRUM ST
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
FOUNTAIN HILL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18015-1155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-954-4960
Provider Business Mailing Address Fax Number:
610-954-3162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 OSTRUM ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
FOUNTAIN HILL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18015-1155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-954-4960
Provider Business Practice Location Address Fax Number:
610-954-3162
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
610-954-3383

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1007307530190 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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