Healthcare Provider Details

I. General information

NPI: 1639655913
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4175 N HANSON CT
BOWIE MD
20716
US

IV. Provider business mailing address

201 DEFENSE HWY STE 150
ANNAPOLIS MD
21401-8953
US

V. Phone/Fax

Practice location:
  • Phone: 301-352-4007
  • Fax: 301-352-3316
Mailing address:
  • Phone: 144-348-1531
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateMD

VIII. Authorized Official

Name: JEANNETTE WOOD
Title or Position: REIMBURSEMENT ADMINISTRATOR
Credential:
Phone: 443-481-6521