Basic Information
| Provider Information | |||||||||
| NPI: | 1942834551 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUMINIS HEALTH MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | METROPOLITAN MEDICAL SPECIALISTS PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434811000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8116 GOOD LUCK RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207063508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015528118 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2020 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | ODENWALD | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| 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 | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.