NPIMap

Organization Active NPI

Centerwell Senior Primary Care (NV) PC

  • Internal Medicine Physician
  • Las Vegas, NV
National Provider Identifier
1003695545
Registry record updated Jul 3, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
CENTERWELL SENIOR PRIMARY CARE (NV) PC
Practice address
691 N Nellis Blvd
Las Vegas, NV 89110-5383
Phone
(702) 430-9996
Fax
(877) 409-2125
NPI assigned
Sep 25, 2023
Organization subpart
Yes
Parent organization
CENTERWELL SENIOR PRIMARY CARE (NV) PCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 3, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Angie Martinez
Title
Senior Credentialing Professional
Phone
(407) 447-7120

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X Primary
Interventional Cardiology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RI0011X
General Practice PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208D00000X

Addresses

Primary practice location

691 N Nellis Blvd
Las Vegas, NV 89110-5383

Mailing address

6101 Blue Lagoon Dr Ste 200
Miami, FL 33126-3168
Phone (305) 500-2000

Other names 1

  • CenterWell Senior Primary Care-Bonanza Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NV

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200901001111 NV Part B Supplier - Clinic/Group Practice 5092132340 Receives reassigned benefits from 97 practitioners
24 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Las Vegas, NV; North Las Vegas, NV; Henderson, NV

Other NPIs on the same Medicare enrollment 23

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 23

National Provider Directory

National Provider Directory
Part of
Centerwell Senior Primary Care NV P C

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1695600000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1719964800000",
    "number": "1003695545",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6101 BLUE LAGOON DR STE 200",
            "city": "MIAMI",
            "state": "FL",
            "postal_code": "331263168",
            "telephone_number": "305-500-2000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "691 N NELLIS BLVD",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891105383",
            "telephone_number": "702-430-9996",
            "fax_number": "877-409-2125"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERWELL SENIOR PRIMARY CARE (NV) PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTERWELL SENIOR PRIMARY CARE (NV) PC",
        "enumeration_date": "2023-09-25",
        "last_updated": "2024-07-03",
        "certification_date": "2024-07-03",
        "status": "A",
        "authorized_official_last_name": "MARTINEZ",
        "authorized_official_first_name": "ANGIE",
        "authorized_official_title_or_position": "SENIOR CREDENTIALING PROFESSIONAL",
        "authorized_official_telephone_number": "407-447-7120"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207RI0011X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Interventional Cardiology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CenterWell Senior Primary Care-Bonanza",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "CenterWell Senior Primary Care-Bonanza",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Las Vegas, NV

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 3, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.