Provider Demographics
NPI:1588047971
Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-481-6549
Mailing Address - Street 1:474B RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-2911
Mailing Address - Country:US
Mailing Address - Phone:410-544-2940
Mailing Address - Fax:410-544-2960
Practice Address - Street 1:474B RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2911
Practice Address - Country:US
Practice Address - Phone:410-544-2940
Practice Address - Fax:410-544-2960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty