Basic Information
| Provider Information | |||||||||
| NPI: | 1457868721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LUMINIS HEALTH MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ANNAPOLIS ONCOLOGY CENTER | ||||||||
| 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: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 183 HARRY S TRUMAN PKWY STE 120 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214017579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105735300 | ||||||||
| FaxNumber: | 4105735305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2018 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | JEANNETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4434816521 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ANNE ARUNDEL PHYSICIAN GROUP, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.