1952564528 NPI number — LUMINIS HEALTH MEDICAL GROUP, LLC

Table of content: (NPI 1952564528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952564528 NPI number — LUMINIS HEALTH MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUMINIS HEALTH MEDICAL GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTREVILLE FAMILY MEDICINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952564528
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12622
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-481-6572
Provider Business Mailing Address Fax Number:
443-481-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 COURSEVALL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTREVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21617-2804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-758-3303
Provider Business Practice Location Address Fax Number:
410-758-3310
Provider Enumeration Date:
07/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ODENWALD
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
VP BUSINESS DEVELOPMENT
Authorized Official Telephone Number:
443-481-6415

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  D35048 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 407175117 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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