MEDICARE: LUMINIS HEALTH MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	K643	OTHER	BCBS
2	955BSO	OTHER	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699742874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUMINIS HEALTH MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	2000 MEDICAL PKWY STE 409
Second Line	:
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-3746
Country	:	US
Telephone Number	:	443-481-5136
Fax Number	:	443-481-6515

Provider Business Practice Location Address
First Line	:	3169 BRAVERTON ST
Second Line	:	SUITE 201
City	:	EDGEWATER
State	:	MD
Zip	:	21037-2679
Country	:	US
Telephone Number	:	410-956-4911
Fax Number	:	410-956-4935

Authorized Official
Title or Position	:	AO
Name	:	MELISSA RAPATTONI
Credential	:
Telephone Number	:	443-481-5136

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	11/05/2024

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