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		PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BS ME1389283	OTHER		GROUP NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801965140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. LUKE'S PHYSICIAN GROUP, INC.

Provider Business Mailing Address
First Line	:	237 E BROWN ST
Second Line	:
City	:	EAST STROUDSBURG
State	:	PA
Zip	:	18301-3005
Country	:	US
Telephone Number	:	570-422-1405
Fax Number	:	570-424-6631

Provider Business Practice Location Address
First Line	:	237 E BROWN ST
Second Line	:
City	:	EAST STROUDSBURG
State	:	PA
Zip	:	18301-3005
Country	:	US
Telephone Number	:	570-422-1405
Fax Number	:	570-424-6631

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DEAN EVANS
Credential	:
Telephone Number	:	610-954-4991

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	04/22/2010

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