Provider Demographics
NPI:1801232962
Name:ST. LUKE'S PHYSICIAN GROUP, INC
Entity type:Organization
Organization Name:ST. LUKE'S PHYSICIAN GROUP, INC
Other - Org Name:
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:484-526-4991
Mailing Address - Street 1:208 LIFELINE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-6473
Mailing Address - Country:US
Mailing Address - Phone:570-476-6700
Mailing Address - Fax:
Practice Address - Street 1:208 LIFELINE RD STE 201
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-6473
Practice Address - Country:US
Practice Address - Phone:570-476-6700
Practice Address - Fax:570-476-0735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-16
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2080A0000X
PA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty