Centerwell Senior Primary Care (SC) PC
Organization Active NPI Family Medicine Physician · Anderson, SC
NPI 1285287482 · NPPES record last updated Aug 19, 2024
Key facts
- NPI
- 1285287482
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- CENTERWELL SENIOR PRIMARY CARE (SC) PC
- Practice address
- 108 Highway 28 Byp
Anderson, SC 29624-3742 - Phone
- (864) 772-8173
- Fax
- (833) 996-1161
- NPI assigned
- Jul 17, 2019
- Organization subpart
- Yes
- Parent organization (as reported)
- CENTERWELL SENIOR PRIMARY CARE (SC) PC
Authorized official
- Name
- Angie Martinez
- Title
- Senior Credentialing Professional
- Phone
- (407) 447-7120
Other NPIs on the same Medicare enrollment 8
Corporate family (same tax ID) 4
Practitioners 6
-
Jill Eileen Kessler, FNP-BC
-
Sarah L Fulaytar, APRN
-
Amy Beth Raz, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 42D2174743 | Centerwell Senior Primary Care - Homeland Park | Certificate of waiver | Nov 6, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in SC
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20201216002926 | SC | Part B Supplier - Clinic/Group Practice | 2860804796 |
Receives reassigned benefits from 85 practitioners 8 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Greenville, SC; Spartanburg, SC; Seneca, SC; North Charleston, SC; Greer, SC; Charleston, SC; Anderson, SC |
National Provider Directory
- Tax ID family
- Centerwell Senior Primary Care NC PC
- Part of
- Centerwell Senior Primary Care NC PC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes | ||
| Internal Medicine Physician |
207R00000X | |||
| General Practice Physician |
208D00000X |
Addresses
Primary practice location
108 Highway 28 Byp
Anderson, SC 29624-3742
Mailing address
6101 Blue Lagoon Dr Ste 200
Miami, FL 33126-3168
Phone (305) 500-2000
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| GP9170 | Medicaid | SC |
Other names
- CenterWell Senior Primary Care-Homeland Park
- Partners in Primary Care- Homeland Park
- Partners in Primary Care NC PC
- Partners in Primary Care SC PC
NPI Registry JSON
{
"created_epoch": "1563321600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1724025600000",
"number": "1285287482",
"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": "108 HIGHWAY 28 BYP",
"city": "ANDERSON",
"state": "SC",
"postal_code": "296243742",
"telephone_number": "864-772-8173",
"fax_number": "833-996-1161"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "CENTERWELL SENIOR PRIMARY CARE (SC) PC",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "CENTERWELL SENIOR PRIMARY CARE (SC) PC",
"enumeration_date": "2019-07-17",
"last_updated": "2024-08-19",
"certification_date": "2024-08-19",
"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": true
},
{
"code": "207R00000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Internal Medicine",
"state": null,
"license": null,
"primary": false
},
{
"code": "208D00000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "General Practice",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "GP9170",
"state": "SC"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "CenterWell Senior Primary Care-Homeland Park",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "Partners in Primary Care- Homeland Park",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "Partners in Primary Care NC PC",
"code": "4",
"type": "Former Legal Business Name"
},
{
"organization_name": "Partners in Primary Care NC PC",
"code": "4",
"type": "Former Legal Business Name"
},
{
"organization_name": "Partners in Primary Care SC PC",
"code": "4",
"type": "Former Legal Business Name"
}
]
}Other providers in Anderson, SC
- Amber Dawn Caulder
- Adrianne J. Cauley
- Brooks C. Cauley
- Maria A. Cayelli
- Centerwell Pharmacy, Inc.
- Centerwell Senior Primary Care (SC) PC
- Sherry Cason Chafin
- Matthew Carter Chambers
- Jason Andrew Champ
- Jerry D Champ
All providers in Anderson, SC · Family Medicine Physician in South Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 19, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.