MEDICARE: LUMA HEALTHCARE, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207SG0201X	Clinical Genetics (M.D.) Physician
2	207V00000X	Obstetrics & Gynecology Physician
3	207VX0000X	Obstetrics Physician
4	208000000X	Pediatrics Physician
5	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972861623
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUMA HEALTHCARE, INC

Provider Business Mailing Address
First Line	:	2311 W GOOD HOPE RD
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53209-2735
Country	:	US
Telephone Number	:	414-228-0100
Fax Number	:

Provider Business Practice Location Address
First Line	:	1919 W NORTH AVE # 200
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-1153
Country	:	US
Telephone Number	:	414-287-1000
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	MRS. MARIA DE ELEJALDE
Credential	:
Telephone Number	:	414-228-0100

Provider Enumeration Date	:	05/01/2012
Last Update Date	:	07/09/2013

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Directions to “LUMA HEALTHCARE, INC ” Practice Location

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