Basic Information
Provider Information | |||||||||
NPI: | 1003392382 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LUMINIS HEALTH MEDICAL GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AAMG CHESAPEAKE WOMEN'S HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 201 DEFENSE HWY STE 150 | ||||||||
Address2: |   | ||||||||
City: | ANNAPOLIS | ||||||||
State: | MD | ||||||||
PostalCode: | 214018953 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 1443481531 | ||||||||
FaxNumber: | 4434816515 | ||||||||
Practice Location | |||||||||
Address1: | 100 BRAMBLE ST STE E&F | ||||||||
Address2: |   | ||||||||
City: | CAMBRIDGE | ||||||||
State: | MD | ||||||||
PostalCode: | 216132471 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108200038 | ||||||||
FaxNumber: | 4108200039 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2018 | ||||||||
LastUpdateDate: | 05/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WOOD | ||||||||
AuthorizedOfficialFirstName: | JEANNETTE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | REIMBURSEMENT ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 4434816521 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X |   | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Midwife |   |
ID Information
ID | Type | State | Issuer | Description | CC3700 | 01 | MD | CAREFIRST | OTHER |