MEDICARE: ST. LUKE'S PHYSICIAN GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1407339856
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. LUKE'S PHYSICIAN GROUP

Provider Business Mailing Address
First Line	:	801 OSTRUM ST
Second Line	:
City	:	BETHLEHEM
State	:	PA
Zip	:	18015-1000
Country	:	US
Telephone Number	:	484-526-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	419 KING ST
Second Line	:
City	:	EAST STROUDSBURG
State	:	PA
Zip	:	18301-1206
Country	:	US
Telephone Number	:	570-424-8300
Fax Number	:	570-424-8301

Authorized Official
Title or Position	:	SUPERVISOR
Name	:	SUE CHIAVAROLI
Credential	:
Telephone Number	:	484-526-3569

Provider Enumeration Date	:	09/12/2018
Last Update Date	:	09/12/2018

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