1588682389 NPI number — LUMINIS HEALTH MEDICAL GROUP, LLC

Table of content: (NPI 1447602792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588682389 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:
1588682389
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:
443-481-6483
Provider Business Mailing Address Fax Number:
443-481-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2009 TIDEWATER COLONY
Provider Second Line Business Practice Location Address:
SUITE 2A
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:
410-224-0010
Provider Business Practice Location Address Fax Number:
410-224-0012
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLARKE
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
443-481-1000

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  D0018529 , 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)

  • Identifier: 953BAN . This is a "BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: K640 . This is a "BCBS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 407175109 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com