Provider Demographics
NPI:1215269311
Name:CENTERWELL SENIOR PRIMARY CARE (FL) INC.
Entity type:Organization
Organization Name:CENTERWELL SENIOR PRIMARY CARE (FL) INC.
Other - Org Name:<UNAVAIL>
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 1:4700 MILLENIA BLVD STE 650
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-6013
Mailing Address - Country:US
Mailing Address - Phone:407-447-7120
Mailing Address - Fax:
Practice Address - Street 1:911 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5029
Practice Address - Country:US
Practice Address - Phone:407-933-2690
Practice Address - Fax:321-281-8772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-01
Last Update Date:2024-05-10
Deactivation Date:2021-08-16
Deactivation Code:
Reactivation Date:2022-04-20
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X, 207R00000X, 207RG0300X, 207R00000X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025017703Medicaid
FL377471600Medicaid
FL377471600Medicaid