Provider Demographics
NPI:1831463298
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: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:443-481-6576
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:1630 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:MD
Practice Address - Zip Code:21619-2791
Practice Address - Country:US
Practice Address - Phone:410-643-4524
Practice Address - Fax:410-643-4523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD830799OtherAETNA HMO
MD8580111OtherAETNA PPO
AB1100OtherCAREFIRST
MD4071751-37Medicaid
129NMedicare PIN
MD830799OtherAETNA HMO