Basic Information
| Provider Information | |||||||||
| NPI: | 1396298816 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUMINIS HEALTH MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | AAMG PSYCHIATRIC DAY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 DEFENSE HWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214018943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816549 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 132 HOLIDAY CT | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214017005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102244207 | ||||||||
| FaxNumber: | 4102245659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2016 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARKE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4434816549 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.