1518444066 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 1518444066 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:
1518444066
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:
201 DEFENSE HWY STE 100
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:
21401-8902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-481-5310
Provider Business Mailing Address Fax Number:
443-481-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 DUTCHMANS LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EASTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21601-4302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-481-1199
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2018

Additional Information

Authorized Official

Authorized Official Last Name:
WOOD
Authorized Official First Name:
JEANNETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
REIMBURSEMENT ADMINISTRATOR
Authorized Official Telephone Number:
443-481-6521

Provider Taxonomy Codes

  • Taxonomy code: 176B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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