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NPI Code Detail

MEDICARE: CENTERWELL SENIOR PRIMARY CARE (NV) PC

MEDICARE: CENTERWELL SENIOR PRIMARY CARE (NV) PC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician
2207RI0011XInterventional Cardiology Physician
3208D00000XGeneral Practice Physician
4207R00000XInternal Medicine Physician

General Provider Information

NPI Number : 1376322537
Entity Type Code : Organization
Provider Name (Legal Business Name) : CENTERWELL SENIOR PRIMARY CARE (NV) PC
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 : 2335 E LAKE MEAD BLVD
Second Line :
City : NORTH LAS VEGAS
State : NV
Zip : 89030-7141
Country : US
Telephone Number : 702-832-4562
Fax Number : 888-481-1462
Authorized Official
Title or Position : SENIOR CREDENTIALING PROFESSIONAL
Name : ANGIE MARTINEZ
Credential :
Telephone Number : 407-447-7120
Provider Enumeration Date : 09/27/2023
Last Update Date : 02/15/2024

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