Healthcare Provider Details

I. General information

NPI: 1063800506
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEDICAL PKWY SUITE 605
ANNAPOLIS MD
21401-3742
US

IV. Provider business mailing address

PO BOX 12622
BELFAST ME
04915-4017
US

V. Phone/Fax

Practice location:
  • Phone: 410-266-5667
  • Fax: 410-266-9332
Mailing address:
  • Phone: 443-481-6460
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN CLARKE
Title or Position: VICE PRESIDENT
Credential:
Phone: 443-481-6476