1063463701 NPI number — ST. LUKE'S PHYSICIAN GROUP, INC.

Table of content: (NPI 1063463701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063463701 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:
1063463701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 OSTRUM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BETHLEHEM
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18015-1000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-863-7020
Provider Business Mailing Address Fax Number:
866-833-9399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
497 BUSHKILL PLAZA LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WIND GAP
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18091-9665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-863-7020
Provider Business Practice Location Address Fax Number:
866-833-9399
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHIAVAROLI
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
484-526-3569

Provider Taxonomy Codes

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

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

  • Identifier: 1007307530018 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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