Provider Demographics
NPI:1588682389
Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Other - Org Name:ANNAPOLIS CENTER FOR INTEGRATIVE MEDICINE
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:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-481-1000
Mailing Address - Street 1:PO BOX 12622
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4017
Mailing Address - Country:US
Mailing Address - Phone:443-481-6483
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2009 TIDEWATER COLONY
Practice Address - Street 2:SUITE 2A
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:410-224-0010
Practice Address - Fax:410-224-0012
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANNE ARUNDEL PHYSICIAN GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-18
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0018529207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD953BANOtherBCBS
DCK640OtherBCBS
MD407175109Medicaid
MDDD3213Medicare PIN
MD129NMedicare PIN