1790283778 NPI number — LUMIN HEALTH PHYSICIAN GROUP PA

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 1790283778 NPI number — LUMIN HEALTH PHYSICIAN GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUMIN HEALTH PHYSICIAN GROUP PA
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:
SPINECARE INSTITUTE, PA
Provider Other Organization Name Type Code:
4
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:
1790283778
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4090 MAPLESHADE LN STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75093-0025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-680-4295
Provider Business Mailing Address Fax Number:
972-265-3001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4090 MAPLESHADE LN STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-0025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-680-4295
Provider Business Practice Location Address Fax Number:
972-265-3001
Provider Enumeration Date:
01/25/2018

Additional Information

Authorized Official

Authorized Official Last Name:
WON
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
972-255-5588

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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