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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1770354979
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	:	443-481-4151

Provider Business Practice Location Address
First Line	:	7611 CRAIN HWY STE 170
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-4258
Country	:	US
Telephone Number	:	443-481-1000
Fax Number	:	443-481-4151

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

Provider Enumeration Date	:	01/16/2024
Last Update Date	:	11/06/2024

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