Healthcare Provider Details

I. General information

NPI: 1780456335
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 GOOD LUCK RD
LANHAM MD
20706-3511
US

IV. Provider business mailing address

201 DEFENSE HWY STE 150
ANNAPOLIS MD
21401-8953
US

V. Phone/Fax

Practice location:
  • Phone: 301-623-4350
  • Fax:
Mailing address:
  • Phone: 443-481-6476
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: PETER ODENWALD
Title or Position: VP BUSINESS DEVELOPMENT
Credential:
Phone: 443-481-1000