Healthcare Provider Details

I. General information

NPI: 1306197132
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEDICAL PKWY STE 309
ANNAPOLIS MD
21401-3745
US

IV. Provider business mailing address

PO BOX 12622
BELFAST ME
04915-4017
US

V. Phone/Fax

Practice location:
  • Phone: 301-352-4007
  • Fax:
Mailing address:
  • Phone: 443-481-6467
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: JEANNETTE WOOD
Title or Position: EXEC. DIR. PHYSICIAN REIMBURSEMENT
Credential:
Phone: 443-481-6476