Provider Demographics
NPI:1831640465
Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Other - Org Name:AAMG DIABETES & ENDOCRINE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:ODENWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-481-6415
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:443-481-6476
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:1450 MERCANTILE LN
Practice Address - Street 2:SUITE 111
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5376
Practice Address - Country:US
Practice Address - Phone:301-925-7610
Practice Address - Fax:301-925-7619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD02332133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
185618Medicare PIN