Basic Information
| Provider Information | |||||||||
| NPI: | 1467767806 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUMINIS HEALTH MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ANNE ARUNDEL MEDICAL GROUP-NEUROLOGY SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816467 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 MEDICAL PKWY | ||||||||
| Address2: | SUITE 430 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434811940 | ||||||||
| FaxNumber: | 4434811941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2010 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARKE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT BUSINESS DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 4434816464 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | X581 | 01 | DC | BCBS | OTHER | 407175122 | 05 | MD | MEDICAID | CF6JAS | 01 | MD | BCBS | OTHER |