Provider Demographics
NPI:1083237465
Name:CENTERWELL SENIOR PRIMARY CARE (NV) PC
Entity Type:Organization
Organization Name:CENTERWELL SENIOR PRIMARY CARE (NV) PC
Other - Org Name:CENTERWELL SENIOR PRIMARY CARE -FREMONT STREET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR CREDENTIALING PROFESSIONAL
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-447-7120
Mailing Address - Street 1:4700 MILLENIA BLVD STE 650
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-6013
Mailing Address - Country:US
Mailing Address - Phone:407-447-7120
Mailing Address - Fax:407-770-0661
Practice Address - Street 1:1766 E CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1945
Practice Address - Country:US
Practice Address - Phone:702-843-2440
Practice Address - Fax:833-749-0349
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTERWELL SENIOR PRIMARY CARE (NV) PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-20
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250009773Medicaid