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	261QM1300X	Multi-Specialty Clinic/Center
4	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1669054961
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	:	407-770-0661

Provider Business Practice Location Address
First Line	:	11978 WESTHEIMER RD STE B
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-6669
Country	:	US
Telephone Number	:	346-275-6750
Fax Number	:	877-542-6970

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

Provider Enumeration Date	:	04/26/2021
Last Update Date	:	10/18/2022

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