Basic Information
| Provider Information | |||||||||
| NPI: | 1720304223 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUMINIS HEALTH MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
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| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816572 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 4175 N HANSON CT | ||||||||
| Address2: | STE 201 | ||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207163179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434811199 | ||||||||
| FaxNumber: | 4434811495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2010 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | ODENWALD | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP BUSINESS DEVELOPMENT | ||||||||
| 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 | 2086X0206X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 407175124 | 05 | MD | MEDICAID | CHD0AA | 01 | MD | BCBS | OTHER | 407175129 | 05 | MD | MEDICAID | X364 | 01 | DC | BCBS | OTHER |