=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437541182
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. LUKE'S PHYSICIAN GROUP INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2015
-----------------------------------------------------
Last Update Date | 01/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1941 HAMILTON ST SUITE 100
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18104-6470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-628-8910
-----------------------------------------------------
Fax | 610-628-8915
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1941 HAMILTON ST SUITE 100
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18104-6470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-628-8910
-----------------------------------------------------
Fax | 610-628-8915
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DEAN W. EVANS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 484-526-4911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------