Provider Demographics
NPI:1639655913
Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Other - Org Name:PREMIER OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REIMBURSEMENT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-481-6521
Mailing Address - Street 1:201 DEFENSE HWY STE 150
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-8953
Mailing Address - Country:US
Mailing Address - Phone:144-348-1531
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:4175 N HANSON CT
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716
Practice Address - Country:US
Practice Address - Phone:301-352-4007
Practice Address - Fax:301-352-3316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-19
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDY88800OtherCAREFIRST