Healthcare Provider Details

I. General information

NPI: 1982671103
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 BRANDERMILL BLVD SUITE 250
GAMBRILLS MD
21054-1690
US

IV. Provider business mailing address

PO BOX 12622
BELFAST ME
04915-4017
US

V. Phone/Fax

Practice location:
  • Phone: 410-721-1507
  • Fax: 410-721-1510
Mailing address:
  • Phone: 443-481-6576
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PETER ODENWALD
Title or Position: VP
Credential:
Phone: 443-481-6415