Basic Information
| Provider Information | |||||||||
| NPI: | 1073580205 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUMINIS HEALTH MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | CENTER FOR MATERNAL AND FETAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816506 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 185 HARRY S TRUMAN PKWY STE 120 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102244442 | ||||||||
| FaxNumber: | 4102248898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 05/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | JEANNETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4434816521 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 760BCE | 01 | BCBS | OTHER | 407175103 | 05 | MD | MEDICAID | 407175112 | 05 | MD | MEDICAID | K480 | 01 | BCBS | OTHER | 297302204 | 05 | MD | MEDICAID | 407175108 | 05 | MD | MEDICAID |