Healthcare Provider Details

I. General information

NPI: 1558810176
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 DUTCHMANS LN
EASTON MD
21601-4302
US

IV. Provider business mailing address

201 DEFENSE HWY SUITE 100
ANNAPOLIS MD
21401-8943
US

V. Phone/Fax

Practice location:
  • Phone: 410-897-0822
  • Fax: 410-897-0095
Mailing address:
  • Phone: 443-481-3354
  • Fax: 443-481-6515

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: MR. STEPHEN CLARKE
Title or Position: VICE PRESIDENT
Credential:
Phone: 443-481-3354