1063837490 NPI number — LUMINIS HEALTH MEDICAL GROUP, LLC

Table of content: (NPI 1063837490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063837490 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:
Provider Other Organization Name Type Code:
6
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:
1063837490
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 DEFENSE HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANNAPOLIS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21401-8943
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-481-1000
Provider Business Mailing Address Fax Number:
443-481-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8109 RITCHIE HWY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21122-6917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-270-8600
Provider Business Practice Location Address Fax Number:
443-270-8990
Provider Enumeration Date:
02/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
RAPATTONI
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
AO
Authorized Official Telephone Number:
443-481-5136

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  D27388 , 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)





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