NPIMap

Organization Active NPI

Centerwell Senior Primary Care FL JV PLLC

Doing business as Conviva Hudson

  • Internal Medicine Physician
  • Hudson, FL
National Provider Identifier
1356178578
Registry record updated Sep 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
CENTERWELL SENIOR PRIMARY CARE FL JV PLLC
Doing business as
Conviva Hudson
Practice address
12582 US Highway 19
Hudson, FL 34667-1952
Phone
(407) 447-7120
NPI assigned
Sep 19, 2024
Last updated
Sep 19, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
CENTERWELL SENIOR PRIMARY CARE FL JV PLLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 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 Physician 207Q00000X NU
Internal Medicine Physician 207R00000X NU Primary
General Practice Physician 208D00000X NU

Addresses

Primary practice location

12582 US Highway 19
Hudson, FL 34667-1952

Mailing address

6101 Blue Lagoon Dr Ste 200
Miami, FL 33126-3168
Phone (407) 447-7120

Other names 1

  • Conviva Hudson Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20241008003187 FL Part B Supplier - Clinic/Group Practice 5698206167 Receives reassigned benefits from 34 practitioners
10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Jacksonville, FL; Winter Garden, FL; Wesley Chapel, FL; St Petersburg, FL; Sanford, FL; Orlando, FL; New Port Richey, FL; Hudson, FL

Other NPIs on the same Medicare enrollment 10

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
10D2318674Centerwell Senior Primary Care FL JV PLLC12582 US Highway 19, Hudson, FL 34667Certificate of waiverFeb 13, 2027

National Provider Directory

National Provider Directory
Tax ID family
Centerwell Senior Primary Care FL JV PLLC10 organizations share this tax ID, including this one
Part of
Centerwell Senior Primary Care FL JV PLLC

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

Locations

12582 US Highway 19
Hudson, FL 34667
Phone (727) 516-8806

10991 San Jose Blvd
#100
Jacksonville, FL 32223
Phone (904) 839-1263

11900 Atlantic Blvd
#1
Jacksonville, FL 32225
Phone (904) 839-1037

4250 Philips Hwy
#100
Jacksonville, FL 32207
Phone (904) 839-1018

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 36

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 36

NPI Registry JSON

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

{
    "created_epoch": "1726704000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1726704000000",
    "number": "1356178578",
    "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": "407-447-7120",
            "fax_number": "407-770-0661"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12582 US HIGHWAY 19",
            "city": "HUDSON",
            "state": "FL",
            "postal_code": "346671952",
            "telephone_number": "407-447-7120"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERWELL SENIOR PRIMARY CARE FL JV PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTERWELL SENIOR PRIMARY CARE FL JV PLLC",
        "enumeration_date": "2024-09-19",
        "last_updated": "2024-09-19",
        "certification_date": "2024-09-19",
        "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": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Conviva Hudson",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Hudson, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 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.