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	2080A0000X	Pediatric Adolescent Medicine Physician
2	208000000X	Pediatrics Physician		PA

General Provider Information

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

Provider Business Mailing Address
First Line	:	208 LIFELINE RD STE 201
Second Line	:
City	:	STROUDSBURG
State	:	PA
Zip	:	18360-6473
Country	:	US
Telephone Number	:	570-476-6700
Fax Number	:

Provider Business Practice Location Address
First Line	:	208 LIFELINE RD STE 201
Second Line	:
City	:	STROUDSBURG
State	:	PA
Zip	:	18360-6473
Country	:	US
Telephone Number	:	570-476-6700
Fax Number	:	570-476-0735

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

Provider Enumeration Date	:	05/16/2013
Last Update Date	:	02/07/2018

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