1073580205 NPI number — LUMINIS HEALTH MEDICAL GROUP, LLC

Table of content: (NPI 1073580205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073580205 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:
LUMINIS HEALTH MATERNAL AND FETAL 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:
1073580205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 MEDICAL PKWY STE 409
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:
21401-3773
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:
185 HARRY S TRUMAN PKWY STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-224-4442
Provider Business Practice Location Address Fax Number:
410-224-8898
Provider Enumeration Date:
03/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PINKETT
Authorized Official First Name:
SHAWANA
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER ENROLLMENT COORDINATOR
Authorized Official Telephone Number:
443-825-8275

Provider Taxonomy Codes

  • Taxonomy code: 207VM0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 297302204 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 407175103 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 407175108 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 760BCE . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 407175112 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: K480 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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