Provider Demographics
NPI:1477862308
Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Other - Org Name:AAMC COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT- PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-481-6464
Mailing Address - Street 1:PO BOX 62551
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2551
Mailing Address - Country:US
Mailing Address - Phone:443-481-6572
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:1419 FOREST DR
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-1482
Practice Address - Country:US
Practice Address - Phone:410-990-0050
Practice Address - Fax:410-990-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
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
MD407175128Medicaid
MD129NMedicare PIN