MEDICARE: CENTERWELL SENIOR PRIMARY CARE (TX) PA

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	208D00000X	General Practice Physician
3	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1679212955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTERWELL SENIOR PRIMARY CARE (TX) PA

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	:	407-770-0661

Provider Business Practice Location Address
First Line	:	4200 SOUTH FWY STE 1990
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-1415
Country	:	US
Telephone Number	:	682-990-6491
Fax Number	:	877-675-3246

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

Provider Enumeration Date	:	06/03/2022
Last Update Date	:	10/18/2022

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