NPIMap

Organization Active NPI

Centerwell Senior Primary Care SC JV PC

  • Internal Medicine Physician
  • Columbia, SC
National Provider Identifier
1356040992
Registry record updated Aug 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
CENTERWELL SENIOR PRIMARY CARE SC JV PC
Practice address
2738 Decker Blvd Ste a
Columbia, SC 29206-1735
Phone
(803) 969-0543
Fax
(877) 958-9029
NPI assigned
Mar 2, 2023
Organization subpart
Yes
Parent organization
CENTERWELL SENIOR PRIMARY CARE SC JV PCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 19, 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 3

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

Addresses

Primary practice location

2738 Decker Blvd Ste a
Columbia, SC 29206-1735

Mailing address

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

Other names 1

  • CenterWell Senior Primary Care-Decker Blvd Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230426000585 SC Part B Supplier - Clinic/Group Practice 5294190252 Receives reassigned benefits from 39 practitioners
8 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Columbia, SC; West Columbia, SC; North Myrtle Beach, SC; North Augusta, SC; Myrtle Beach, SC; Murrells Inlet, SC

Other NPIs on the same Medicare enrollment 8

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
42D2281256Centerwell Senior Primary Care-Decker Blvd2738 Decker Blvd, Suite a, Columbia, SC 29206Certificate of waiverMay 3, 2027

National Provider Directory

National Provider Directory
Part of
Centerwell Senior Primary Care SC JV PC

Locations

2720 Decker Blvd
Columbia, SC 29206

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1677715200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724025600000",
    "number": "1356040992",
    "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": "2738 DECKER BLVD STE A",
            "city": "COLUMBIA",
            "state": "SC",
            "postal_code": "292061735",
            "telephone_number": "803-969-0543",
            "fax_number": "877-958-9029"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERWELL SENIOR PRIMARY CARE SC JV PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTERWELL SENIOR PRIMARY CARE SC JV PC",
        "enumeration_date": "2023-03-02",
        "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": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "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-Decker Blvd",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Columbia, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.