Basic Information
| Provider Information | |||||||||
| NPI: | 1639655913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LUMINIS HEALTH MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PREMIER OB/GYN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 DEFENSE HWY STE 150 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214018953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1443481531 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 4175 N HANSON CT | ||||||||
| Address2: | |||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013524007 | ||||||||
| FaxNumber: | 3013523316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2018 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | JEANNETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4434816521 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | Y88800 | 01 | MD | CAREFIRST | OTHER |