Healthcare Provider Details

I. General information

NPI: 1093284853
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 AURORA ST
CAMBRIDGE MD
21613-1903
US

IV. Provider business mailing address

2001 MEDICAL PKWY MEDICAL STAFF OFFICE
ANNAPOLIS MD
21401-3773
US

V. Phone/Fax

Practice location:
  • Phone: 410-897-0822
  • Fax: 410-897-0095
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JEANNETTE WOOD
Title or Position: EXEC DIRECT OF PHYS REIMBURSEMENT
Credential:
Phone: 443-481-6521