1700113776 NPI number — LUMINIS HEALTH MEDICAL GROUP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700113776 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:
ANNAPOLIS SURGICAL ONCOLOGY ASSOCIATES
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:
1700113776
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:
443-481-6538
Provider Business Mailing Address Fax Number:
443-481-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1630 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 213
Provider Business Practice Location Address City Name:
CHESTER
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21619-2791
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-266-9966
Provider Business Practice Location Address Fax Number:
410-266-6819
Provider Enumeration Date:
11/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ODENWALD
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
443-481-6415

Provider Taxonomy Codes

  • Taxonomy code: 2086X0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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