Basic Information
| Provider Information | |||||||||
| NPI: | 1285953182 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUMINIS HEALTH MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | INTENSIVISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 412752 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022410275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434811000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 MEDICAL PKWY | ||||||||
| Address2: | ACUTE CARE PAVILION | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434811000 | ||||||||
| FaxNumber: | 4434811687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2010 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARKE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VP BUSINESS DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 4434816476 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | CS95AA | 01 | CAREFIRST MARYLAND | OTHER | 145724700 | 01 | DEPT OF LABOR, WORKMAN'S COMP | OTHER | 407175115 | 05 | MD | MEDICAID | V814 | 01 | CAREFIRST | OTHER |