Healthcare Provider Details

I. General information

NPI: 1790262244
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 ANNAPOLIS RD STE 220
ODENTON MD
21113-1740
US

IV. Provider business mailing address

201 DEFENSE HWY STE 100
ANNAPOLIS MD
21401-8902
US

V. Phone/Fax

Practice location:
  • Phone: 443-481-1199
  • Fax: 443-481-1495
Mailing address:
  • Phone: 443-481-5310
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name: PETER ODENWALD
Title or Position: REIMBURSEMENT ADMINISTRATORS
Credential:
Phone: 443-481-6415