NPIMap

Organization Active NPI

Centerwell Senior Primary Care (Ky) PSC

  • Internal Medicine Physician
  • Louisville, KY
National Provider Identifier
1699549683
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 (KY) PSC
Practice address
4917 Dixie Hwy Ste E
Louisville, KY 40216-2565
Phone
(407) 447-7120
Fax
(877) 243-0175
NPI assigned
Nov 9, 2023
Organization subpart
Yes
Parent organization
CENTERWELL SENIOR PRIMARY CARE (KY) PSCAs 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 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

4917 Dixie Hwy Ste E
Louisville, KY 40216-2565

Mailing address

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

Other names 1

  • CenterWell Senior Primary Care- Dixie Highway Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220824003346 KY Part B Supplier - Clinic/Group Practice 8022492024 Receives reassigned benefits from 53 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Louisville, KY; Lexington, KY; Frankfort, KY

Other NPIs on the same Medicare enrollment 6

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
18D2303650Centerwell Senior Primary Care-Dixie Highway4917 Dixie Highway Suite E, Louisville, KY 40216Certificate of waiverApr 28, 2028

National Provider Directory

National Provider Directory
Tax ID family
Centerwell Senior Primary Care Ky PSC7 organizations share this tax ID, including this one
Part of
Centerwell Senior Primary Care Ky PSC

Other organizations with this tax ID 6

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

Locations

4917 Dixie Hwy
Louisville, KY 40216

Practitioners & affiliated clinicians

Practitioners 43

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

View all 43

NPI Registry JSON

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

{
    "created_epoch": "1699488000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724284800000",
    "number": "1699549683",
    "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": "4917 DIXIE HWY STE E",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402162565",
            "telephone_number": "407-447-7120",
            "fax_number": "877-243-0175"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERWELL SENIOR PRIMARY CARE (KY) PSC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTERWELL SENIOR PRIMARY CARE (KY) PSC",
        "enumeration_date": "2023-11-09",
        "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": "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- Dixie Highway",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "CenterWell Senior Primary Care- Dixie Highway",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Louisville, KY

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.