Basic Information
| Provider Information | |||||||||
| NPI: | 1629577424 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUMINIS HEALTH MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | AAMG ANNAPOLIS OB-GYN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 DEFENSE HIGHWAY SUITE 150 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21401 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 18 MAGOTHY BEACH ROAD SUITE A | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105739530 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2018 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | ODENWALD | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4434816415 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.