Basic Information
| Provider Information | |||||||||
| NPI: | 1376030585 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. LUKE'S PHYSICIAN GROUP, INC. | ||||||||
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| OtherOrganizationName: | WALBERT AVE PRIMARY CARE ST. LUKE'S SACRED HEART | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 OSTRUM ST | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180151000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845266048 | ||||||||
| FaxNumber: | 8332136428 | ||||||||
| Practice Location | |||||||||
| Address1: | 3420 WALBERT AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105308413 | ||||||||
| FaxNumber: | 6105308418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2018 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | MINAHAN | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4845266162 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.