MEDICARE: ST. LUKE'S PHYSICIAN GROUP, INC.

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	207R00000X	Internal Medicine Physician	MD065140L	PA

General Provider Information

NPI Number	:	1629489562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. LUKE'S PHYSICIAN GROUP, INC.

Provider Business Mailing Address
First Line	:	208 LIFELINE RD
Second Line	:	SUITE 203
City	:	STROUDSBURG
State	:	PA
Zip	:	18360-6473
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	208 LIFELINE RD
Second Line	:	SUITE 203
City	:	STROUDSBURG
State	:	PA
Zip	:	18360-6473
Country	:	US
Telephone Number	:	484-526-4999
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DEAN W EVANS
Credential	:
Telephone Number	:	484-526-4991

Provider Enumeration Date	:	05/14/2014
Last Update Date	:	05/14/2014

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