=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740833938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTERWELL SENIOR PRIMARY CARE (SC) PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2019
-----------------------------------------------------
Last Update Date | 08/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 SAM RITTENBERG BLVD STE 6
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29407-5031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-973-5393
-----------------------------------------------------
Fax | 833-994-1098
-----------------------------------------------------
=====================================================
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 | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------