=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629577424
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUMINIS HEALTH MEDICAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2018
-----------------------------------------------------
Last Update Date | 05/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 MAGOTHY BEACH ROAD SUITE A
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-573-9530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 DEFENSE HIGHWAY SUITE 150
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REIMBURSEMENT ADMINISTRATOR
-----------------------------------------------------
Name | PETER ODENWALD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-481-6415
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------