Provider Demographics
NPI:1891130209
Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Other - Org Name:ANNE ARUNDEL MEDICAL GROUP CARDIOLOGY 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 412752
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2752
Mailing Address - Country:US
Mailing Address - Phone:443-481-6577
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2000 MEDICAL PKWY STE 510
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3747
Practice Address - Country:US
Practice Address - Phone:443-481-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD56089207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
129NMedicare PIN