Organization
LUMINIS HEALTH MEDICAL GROUP, LLC
Active
Other names
Eastern Shore Primary Care
Organization subpart
No
Provider details
NPI number
Authorized official
PETER ODENWALD (VICE PRESIDENT)
(443) 481-6415
Entity
Organization
Contact information
Practice address
1630 MAIN ST, CHESTER, MD 21619-2791
(410) 643-4524
(410) 643-4523
Mailing address
PO BOX 12622, BELFAST, ME 04915-4017
(443) 481-6576
(443) 481-6515
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
4071751-37
—
MD
01
—
830799
AETNA HMO
MD
01
—
8580111
AETNA PPO
MD
01
—
AB1100
CAREFIRST
—
Enumeration date
03/02/2012
Last updated
05/24/2021
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