Provider Demographics
NPI:1295063923
Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:LUMINIS HEALTH MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-481-6476
Mailing Address - Street 1:PO BOX 412752
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-4017
Mailing Address - Country:US
Mailing Address - Phone:443-481-6538
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:1630 MAIN ST
Practice Address - Street 2:SUITE 213
Practice Address - City:CHESTER
Practice Address - State:MD
Practice Address - Zip Code:21619-2791
Practice Address - Country:US
Practice Address - Phone:443-481-3300
Practice Address - Fax:443-481-3315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD153989Medicare PIN