1700989613 NPI number — ST. LUKE'S PHYSICIAN GROUP, INC.

Table of content: DR. JUSTIN JONATHAN MOWCHUN MD (NPI 1780782912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700989613 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:
Provider Other Organization Name Type Code:
6
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:
1700989613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
623 E BROAD ST
Provider Second Line Business Mailing Address:
2ND FLR
Provider Business Mailing Address City Name:
BETHLEHEM
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18018-6332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-954-4766
Provider Business Mailing Address Fax Number:
610-954-3189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 ASH LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIEGELSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-749-2118
Provider Business Practice Location Address Fax Number:
610-749-0936
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EVAN
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
610-954-4991

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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