Healthcare Provider Details

I. General information

NPI: 1407227598
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PURDY ST SUITE 102
EASTON MD
21601-4060
US

IV. Provider business mailing address

PO BOX 12622
BELFAST ME
04915-4017
US

V. Phone/Fax

Practice location:
  • Phone: 410-820-0039
  • Fax: 410-820-0039
Mailing address:
  • Phone: 443-481-6476
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD76431
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberR217803
License Number StateMD

VIII. Authorized Official

Name: STEPHEN L CLARKE
Title or Position: VICE PRESIDENT
Credential:
Phone: 443-481-6476