Provider Demographics
NPI:1720304223
Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:ODENWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-481-6415
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:667-204-7212
Mailing Address - Fax:443-481-4151
Practice Address - Street 1:4175 N HANSON CT STE 203
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3183
Practice Address - Country:US
Practice Address - Phone:443-481-1199
Practice Address - Fax:443-481-1495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-09
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407175124Medicaid
DCX364OtherBCBS
MD407175129Medicaid
MDCHD0AAOtherBCBS
MDCHD0AAOtherBCBS