1700984622 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 1700984622 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:
SOUTH MOUNTAIN FAMILY PRACTICE
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:
1700984622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1545 BROADWAY
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:
18015-3901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-865-6112
Provider Business Mailing Address Fax Number:
610-865-3307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1545 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BETHLEHEM
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18015-3901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-865-6112
Provider Business Practice Location Address Fax Number:
610-865-3307
Provider Enumeration Date:
09/21/2006

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:
610-954-4991

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 310400000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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