Healthcare Provider Details

I. General information

NPI: 1912376955
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MEDICAL PKWY
ANNAPOLIS MD
21401-3773
US

IV. Provider business mailing address

2001 MEDICAL PKWY
ANNAPOLIS MD
21401-3773
US

V. Phone/Fax

Practice location:
  • Phone: 443-481-1000
  • Fax: 443-481-6515
Mailing address:
  • Phone: 443-481-1000
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER ODENWALD
Title or Position: VICE PRESIDENT
Credential:
Phone: 443-481-6415