Provider Demographics
NPI:1528132107
Name:ST LUKE'S PHYSICIAN GROUP INC
Entity type:Organization
Organization Name:ST LUKE'S PHYSICIAN GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ANESTHESIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SMITA
Authorized Official - Middle Name:SATISH
Authorized Official - Last Name:MODY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-645-8121
Mailing Address - Street 1:360 W RUDDLE ST
Mailing Address - Street 2:
Mailing Address - City:COALDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18218-1027
Mailing Address - Country:US
Mailing Address - Phone:570-645-8121
Mailing Address - Fax:570-645-8875
Practice Address - Street 1:360 W RUDDLE ST
Practice Address - Street 2:
Practice Address - City:COALDALE
Practice Address - State:PA
Practice Address - Zip Code:18218-1027
Practice Address - Country:US
Practice Address - Phone:570-645-8121
Practice Address - Fax:570-645-8875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034814L207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA051228Medicare ID - Type Unspecified