=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942192810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUX MEDICA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2025
-----------------------------------------------------
Last Update Date | 07/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1447 YORK RD STE 406
-----------------------------------------------------
City | LUTHERVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093-6057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-343-3001
-----------------------------------------------------
Fax | 410-823-0015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 314 CEDAR LN
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21403-3909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-454-1761
-----------------------------------------------------
Fax | 712-208-8175
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | MR. WARREN CLIFTON MCCORMICK
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 443-454-1761
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------