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	:	1255056727
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	:

Provider Business Practice Location Address
First Line	:	725 W PIONEER PKWY
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-4849
Country	:	US
Telephone Number	:	945-899-0770
Fax Number	:	877-694-3502

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

Provider Enumeration Date	:	10/07/2022
Last Update Date	:	08/11/2023

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