Provider Demographics
NPI:1730403304
Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Entity type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-954-3383
Mailing Address - Street 1:125 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:PA
Mailing Address - Zip Code:18013-2615
Mailing Address - Country:US
Mailing Address - Phone:610-588-8282
Mailing Address - Fax:610-588-5761
Practice Address - Street 1:125 S 1ST ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:PA
Practice Address - Zip Code:18013-2615
Practice Address - Country:US
Practice Address - Phone:610-588-8282
Practice Address - Fax:610-588-5761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA686024Medicare PIN