Centerwell Senior Primary Care (SC) PC
Organization Active NPI Internal Medicine Physician · Charleston, SC
NPI 1740833938 · NPPES record last updated Aug 19, 2024
Key facts
- NPI
- 1740833938
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Internal Medicine Physician 207R00000X
- Legal business name
- CENTERWELL SENIOR PRIMARY CARE (SC) PC
- Practice address
- 1401 Sam Rittenberg Blvd Ste 6
Charleston, SC 29407-5031 - Phone
- (843) 973-5393
- Fax
- (833) 994-1098
- 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
Member of 1
Practitioners 7
-
Timothy W Moon, DO
-
Joshua Paul, MD
-
Faith Mayzeck Shuler, APRN
-
Nada Sareini, AGNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 42D2170950 | Centerwell Senior Primary Care- West Ashley | Certificate of waiver | Aug 21, 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
- Part of
- Centerwell Senior Primary Care NC PC
Locations
108 Highway 28 Byp
Anderson, SC 29624
Phone (864) 296-5208
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Internal Medicine Physician |
207R00000X | Yes | ||
| General Practice Physician |
208D00000X |
Addresses
Primary practice location
1401 Sam Rittenberg Blvd Ste 6
Charleston, SC 29407-5031
Mailing address
6101 Blue Lagoon Dr Ste 200
Miami, FL 33126-3168
Phone (305) 500-2000
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| GP9169 | Medicaid | SC | |
| L064 | Other | SC | MEDICARE |
Other names
- CenterWell Senior Primary Care-West Ashley
- Part in Primary Care SC PC
- Partners In Primary Care- West Ashley
- Partners in Primary Care NC PC
Other providers in Charleston, SC
- Sarah K Cederholm
- Kelly Fischer Celek
- Cem Communications LLC
- Center for Therapeutic Massage
- Centerway Behavioral Health LLC
- Joseph Cerenzia
- Leslie Anne S Cerenzia
- Jesus Emanuel Cervantes
- CFD Ji LLC
- CH MH Services (SC), LLC
All providers in Charleston, SC · Internal 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.