Healthcare Provider Details

I. General information

NPI: 1497955272
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 HOLIDAY CT SUITE 210
ANNAPOLIS MD
21401-7005
US

IV. Provider business mailing address

PO BOX 64401
BALTIMORE MD
21264-4935
US

V. Phone/Fax

Practice location:
  • Phone: 410-266-8663
  • Fax: 410-268-6000
Mailing address:
  • Phone: 443-481-6520
  • 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: MR. STEPHEN L CLARKE
Title or Position: VICE PRESIDENT
Credential:
Phone: 443-481-1000