Provider Demographics
NPI:1114734613
Name:CENTERWELL SENIOR PRIMARY CARE (TN) PC
Entity type:Organization
Organization Name:CENTERWELL SENIOR PRIMARY CARE (TN) PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR CREDENTIALING PROFESSIONAL
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-447-7120
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:407-447-7120
Mailing Address - Fax:
Practice Address - Street 1:7643 HIGHWAY 70 S
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37221-1706
Practice Address - Country:US
Practice Address - Phone:615-334-4635
Practice Address - Fax:615-234-4040
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTERWELL SENIOR PRIMARY CARE (TN) PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty