Provider Demographics
NPI:1508995697
Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Other - Org Name:THE COMPREHENSIVE GYNECOLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-481-1000
Mailing Address - Street 1:PO BOX 62283
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-0001
Mailing Address - Country:US
Mailing Address - Phone:443-481-6520
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2401 BRANDERMILL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1690
Practice Address - Country:US
Practice Address - Phone:410-451-0076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407175111Medicaid
MD407175111Medicaid