Provider Demographics
NPI:1093342438
Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Other - Org Name:ADVANCED INTERNAL MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REIMBURSEMENT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSANIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-481-5618
Mailing Address - Street 1:2001 MEDICAL PKWY OFC
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3773
Mailing Address - Country:US
Mailing Address - Phone:443-481-5618
Mailing Address - Fax:
Practice Address - Street 1:2003 MEDICAL PKWY STE 350
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3081
Practice Address - Country:US
Practice Address - Phone:443-481-5618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-25
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDPENDINGMedicaid