Healthcare Provider Details

I. General information

NPI: 1801232962
Provider Name (Legal Business Name): ST. LUKE'S PHYSICIAN GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2013
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 LIFELINE RD STE 201
STROUDSBURG PA
18360-6473
US

IV. Provider business mailing address

208 LIFELINE RD STE 201
STROUDSBURG PA
18360-6473
US

V. Phone/Fax

Practice location:
  • Phone: 570-476-6700
  • Fax: 570-476-0735
Mailing address:
  • Phone: 570-476-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DEAN W EVANS
Title or Position: PRESIDENT
Credential:
Phone: 484-526-4991