Basic Information
Provider Information | |||||||||
NPI: | 1477862308 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LUMINIS HEALTH MEDICAL GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AAMC COMMUNITY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 62551 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212642551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4434816572 | ||||||||
FaxNumber: | 4434816515 | ||||||||
Practice Location | |||||||||
Address1: | 1419 FOREST DR | ||||||||
Address2: |   | ||||||||
City: | ANNAPOLIS | ||||||||
State: | MD | ||||||||
PostalCode: | 214031482 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109900050 | ||||||||
FaxNumber: | 4109900336 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2010 | ||||||||
LastUpdateDate: | 05/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLARKE | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT- PHYSICIAN SERVICES | ||||||||
AuthorizedOfficialTelephone: | 4434816464 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 407175128 | 05 | MD |   | MEDICAID |