Provider Demographics
NPI:1396501201
Name:CENTERWELL SENIOR PRIMARY CARE AZ PC
Entity type:Organization
Organization Name:CENTERWELL SENIOR PRIMARY CARE AZ PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIENNE
Authorized Official - Middle Name:JANSEN
Authorized Official - Last Name:LOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-667-4150
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:13945 W GRAND AVE STE 102
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2437
Practice Address - Country:US
Practice Address - Phone:024-286-9156
Practice Address - Fax:602-429-8531
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTERWELL SENIOR PRIMARY CARE AZ PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-27
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty