Healthcare Provider Details

I. General information

NPI: 1548821374
Provider Name (Legal Business Name): ST LUKE'S PHYSICIAN GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CHEW ST
ALLENTOWN PA
18102-3472
US

IV. Provider business mailing address

ST. LUKE'S CVO 801 OSTRUM ST.
BETHLEHEM PA
18015-1000
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-2400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

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