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General NPI Number Information
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NPI Number | 1982671103
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Entity Type | Organization
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Legal Business Name | LUMINIS HEALTH MEDICAL GROUP, LLC
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Dates
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Enumeration Date | 03/07/2006
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Last Update Date | 05/24/2021
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Provider Practice Location Address
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Address Line | 2401 BRANDERMILL BLVD SUITE 250
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City | GAMBRILLS
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State | MD
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Zip | 21054-1690
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Country | US
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Telephone | 410-721-1507
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Fax | 410-721-1510
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Provider Business Mailing Address
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Address Line | PO BOX 12622
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City | BELFAST
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State | ME
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Zip | 04915-4017
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Country | US
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Telephone | 443-481-6576
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Fax | 443-481-6515
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Authorized Official
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Title or Position | VP
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Name | MR. PETER ODENWALD
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Credential |
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Telephone | 443-481-6415
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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