Healthcare Provider Details

I. General information

NPI: 1629024427
Provider Name (Legal Business Name): ST. LUKE'S PHYSICIAN GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 OSTRUM ST SUITE 302
FOUNTAIN HILL PA
18015-1155
US

IV. Provider business mailing address

701 OSTRUM ST SUITE 302
FOUNTAIN HILL PA
18015-1155
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-6000
  • Fax: 484-526-9410
Mailing address:
  • Phone: 484-526-6000
  • Fax: 484-526-9410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

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