Provider Demographics
NPI:1023085222
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:MR
Authorized Official - First Name:STEVE
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 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:443-481-5047
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:1460 RITCHIE HWY
Practice Address - Street 2:SUITE 202
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-2497
Practice Address - Country:US
Practice Address - Phone:410-757-6327
Practice Address - Fax:410-757-8461
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANNE ARUNDEL PHYSICIAN GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-07
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407175118Medicaid
DCK642OtherBCBS
MD954BAROtherBCBS
MD954BAROtherBCBS
DCK642OtherBCBS