Healthcare Provider Details

I. General information

NPI: 1154148435
Provider Name (Legal Business Name): CENTERWELL SENIOR PRIMARY CARE (MO) PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 01/09/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7209 N PROSPECT AVE.
GLADSTONE MO
64119-5351
US

IV. Provider business mailing address

6101 BLUE LAGOON DR STE 200
MIAMI FL
33126-3168
US

V. Phone/Fax

Practice location:
  • Phone: 816-429-1396
  • Fax: 816-256-4168
Mailing address:
  • Phone: 407-447-7120
  • Fax: 407-770-0661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGIE MARTINEZ
Title or Position: SENIOR CREDENTIALING PROFESSIONAL
Credential:
Phone: 407-447-7120