1124685425 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 1124685425 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:
1124685425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2021
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:
484-526-3571
Provider Business Mailing Address Fax Number:
833-213-6428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 W RUDDLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COALDALE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18218-1027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-526-2200
Provider Business Practice Location Address Fax Number:
484-526-2398
Provider Enumeration Date:
05/22/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GIGLIO
Authorized Official First Name:
TAMI
Authorized Official Middle Name:
Authorized Official Title or Position:
ENROLLMENT SPECIALIST
Authorized Official Telephone Number:
484-526-3571

Provider Taxonomy Codes

  • Taxonomy code: 2086S0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 034134 . This is a "MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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