Provider Demographics
NPI:1972910792
Name:ST. LUKE'S WARREN PHYSICIAN GROUP, PC
Entity type:Organization
Organization Name:ST. LUKE'S WARREN PHYSICIAN GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF MEDICAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:908-847-6702
Mailing Address - Street 1:37 RUPELL RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08827-4017
Mailing Address - Country:US
Mailing Address - Phone:908-735-7060
Mailing Address - Fax:866-289-8938
Practice Address - Street 1:37 RUPELL RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08827-4017
Practice Address - Country:US
Practice Address - Phone:908-735-7060
Practice Address - Fax:908-735-9922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-14
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029921Medicaid
NJ054761Medicare PIN