NPIMap

Organization Active NPI

Centerwell Senior Primary Care (la) PC

Doing business as CenterWell Senior Primary Care- South Shreveport

  • Internal Medicine Physician
  • Shreveport, LA
National Provider Identifier
1497525661
Registry record updated Aug 22, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
CENTERWELL SENIOR PRIMARY CARE (LA) PC
Doing business as
CenterWell Senior Primary Care- South Shreveport
Practice address
2020 Bert Kouns Industrial Loop
Shreveport, LA 71118-3315
Phone
(407) 447-7120
NPI assigned
Jan 8, 2024
Last updated
Aug 22, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
CENTERWELL SENIOR PRIMARY CARE (LA) PCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 22, 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

2020 Bert Kouns Industrial Loop
Shreveport, LA 71118-3315

Mailing address

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

Other names 1

  • CenterWell Senior Primary Care- South Shreveport Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210217000212 LA Part B Supplier - Clinic/Group Practice 1951712280 Receives reassigned benefits from 60 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Denham Springs, LA; Slidell, LA; Shreveport, LA; Prairieville, LA; Opelousas, LA; New Orleans, LA; Marrero, LA; Lake Charles, LA…

Other NPIs on the same Medicare enrollment 13

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

View all 13

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
19D2308160Centerwell Senior Primary Care - S Shreveport2020 Bert Kouns Industrial Loop, Shreveport, LA 71118Certificate of waiverJul 22, 2028

National Provider Directory

National Provider Directory
Tax ID family
Centerwell Sen Prim Care la14 organizations share this tax ID, including this one
Part of
Centerwell Sen Prim Care la

Other organizations with this tax ID 13

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

View all 13

Practitioners & affiliated clinicians

Practitioners 2

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.

NPI Registry JSON

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

{
    "created_epoch": "1704672000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724284800000",
    "number": "1497525661",
    "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": "2020 BERT KOUNS INDUSTRIAL LOOP",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711183315",
            "telephone_number": "407-447-7120"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERWELL SENIOR PRIMARY CARE (LA) PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTERWELL SENIOR PRIMARY CARE (LA) PC",
        "enumeration_date": "2024-01-08",
        "last_updated": "2024-08-22",
        "certification_date": "2024-08-22",
        "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": "CenterWell Senior Primary Care- South Shreveport",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "CenterWell Senior Primary Care- South Shreveport",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shreveport, LA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 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.