Provider Demographics
NPI:1750901781
Name:CENTERWELL SENIOR PRIMARY CARE (TX) PA
Entity type:Organization
Organization Name:CENTERWELL SENIOR PRIMARY CARE (TX) PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:9688 FM 1960 BYPASS RD W
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-4040
Practice Address - Country:US
Practice Address - Phone:281-318-2401
Practice Address - Fax:833-749-0334
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTERWELL SENIOR PRIMARY CARE (TX) PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-04-20
Last Update Date:2022-10-18
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4165003-01Medicaid
TX792121OtherMEDICARE