Provider Demographics
NPI:1699742874
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:AO
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAPATTONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-481-5136
Mailing Address - Street 1:2000 MEDICAL PKWY STE 409
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3746
Mailing Address - Country:US
Mailing Address - Phone:443-481-5136
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:3169 BRAVERTON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-2679
Practice Address - Country:US
Practice Address - Phone:410-956-4911
Practice Address - Fax:410-956-4935
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANNE ARUNDEL PHYSICIAN GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-07
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K643OtherBCBS
955BSOOtherBCBS
MD407175107Medicaid
955BSOOtherBCBS
K643OtherBCBS