MEDICARE: CENTERWELL SENIOR PRIMARY CARE (NV) PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207Q00000X	Family Medicine Physician
2	207RI0011X	Interventional Cardiology Physician
3	208D00000X	General Practice Physician
4	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1306625835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTERWELL SENIOR PRIMARY CARE (NV) PC

Provider Business Mailing Address
First Line	:	4700 MILLENIA BLVD STE 650
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32839-6013
Country	:	US
Telephone Number	:	407-447-7120
Fax Number	:

Provider Business Practice Location Address
First Line	:	4469 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1605
Country	:	US
Telephone Number	:	702-832-4561
Fax Number	:	210-761-3397

Authorized Official
Title or Position	:	SENIOR CREDENTIALING PROFESSIONAL
Name	:	ANGIE MARTINEZ
Credential	:
Telephone Number	:	407-447-7120

Provider Enumeration Date	:	09/25/2023
Last Update Date	:	02/15/2024

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