Provider Demographics
NPI:1841644580
Name:CENTERWELL SENIOR PRIMARY CARE (SC) PC
Entity type:Organization
Organization Name:CENTERWELL SENIOR PRIMARY CARE (SC) PC
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 1:6101 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 1:3516 HIGHWAY 153
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-7553
Practice Address - Country:US
Practice Address - Phone:864-729-6626
Practice Address - Fax:855-617-4425
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTERWELL SENIOR PRIMARY CARE (SC) PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-19
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCL064OtherMEDICARE
SCGP7379Medicaid