Healthcare Provider Details

I. General information

NPI: 1720304223
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2010
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4175 N HANSON CT STE 203
BOWIE MD
20716-3183
US

IV. Provider business mailing address

2000 MEDICAL PKWY STE 409
ANNAPOLIS MD
21401-3746
US

V. Phone/Fax

Practice location:
  • Phone: 443-481-1199
  • Fax: 443-481-1495
Mailing address:
  • Phone: 667-204-7212
  • Fax: 443-481-4151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER ODENWALD
Title or Position: VP BUSINESS DEVELOPMENT
Credential:
Phone: 443-481-6415