Healthcare Provider Details

I. General information

NPI: 1104443035
Provider Name (Legal Business Name): ST. LUKE'S WARREN PHYSICIAN GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 ROUTE 31 SOUTH
WASHINGTON NJ
07882
US

IV. Provider business mailing address

77 S COMMERCE WAY
BETHLEHEM PA
18017-8891
US

V. Phone/Fax

Practice location:
  • Phone: 484-503-7546
  • Fax: 833-214-0129
Mailing address:
  • Phone: 484-526-3830
  • Fax: 833-213-6428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUE CHIAVAROLI
Title or Position: ENROLLMENT SUPERVISOR
Credential:
Phone: 484-526-3569