Healthcare Provider Details

I. General information

NPI: 1295876167
Provider Name (Legal Business Name): ST. LUKE'S PHYSICIAN GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 BRODHEAD RD
BETHLEHEM PA
18017-8931
US

IV. Provider business mailing address

623 E BROAD ST 2ND FLR
BETHLEHEM PA
18018-6332
US

V. Phone/Fax

Practice location:
  • Phone: 610-954-4975
  • Fax:
Mailing address:
  • Phone: 610-954-6048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number StatePA

VIII. Authorized Official

Name: DEAN W EVANS
Title or Position: PRESIDENT
Credential:
Phone: 610-954-4991