=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326868878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTERWELL SENIOR PRIMARY CARE GA PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2024
-----------------------------------------------------
Last Update Date | 01/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2104 E VICTORY DR
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31404-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-600-1222
-----------------------------------------------------
Fax | 912-600-1262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6101 BLUE LAGOON DR STE 200
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-3168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-500-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR CREDENTIALING PROFESSIONAL
-----------------------------------------------------
Name | ANGIE MARTINEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-447-7120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------