NPIMap

Organization Active NPI

Centerwell Senior Primary Care Ga PC

  • Internal Medicine Physician
  • Stone Mountain, GA
National Provider Identifier
1760059331
Registry record updated Aug 24, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
CENTERWELL SENIOR PRIMARY CARE GA PC
Practice address
5244 Memorial Drive
Suite 1101
Stone Mountain, GA 30083-3157
Phone
(404) 905-0100
Fax
(877) 890-2406
NPI assigned
Jun 10, 2021
Organization subpart
Yes
Parent organization
CENTERWELL SENIOR PRIMARY CARE GA PCAs reported in NPPES

Authorized official

NPPES NPI Registry
Name
Angie Martinez
Title
Credentialing Supervisor
Phone
(407) 447-7120

Other NPIs on the same Medicare enrollment 12

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

Practitioners 8

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

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
11D2255911Centerwell Senior Primary Care - Stone Mountain5244 Memorial Drive Suite #1101, Stone Mountain, GA 30083Certificate of waiverMar 17, 2028

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210901004313 GA Part B Supplier - Clinic/Group Practice 3274939061 Receives reassigned benefits from 69 practitioners
12 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Atlanta, GA; Woodstock, GA; Suwanee, GA; Stone Mountain, GA; South Fulton, GA; Savannah, GA; Morrow, GA; Marietta, GA…

National Provider Directory

National Provider Directory
Tax ID family
Centerwell Senior Primary Care Ga PC13 organizations share this tax ID, including this one
Part of
Centerwell Senior Primary Care Ga PC

Other organizations with this tax ID 12

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

Locations

5244 Memorial Dr
Stone Mountain, GA 30083

Specialties & licenses 3

NPPES NPI Registry
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

NPPES NPI Registry

Primary practice location

5244 Memorial Drive
Suite 1101
Stone Mountain, GA 30083-3157

Mailing address

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

Other names 1

NPPES NPI Registry
  • CenterWell Senior Primary Care-Stone Mountain Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Aug 24, 2026.

{
    "created_epoch": "1623283200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1787529600000",
    "number": "1760059331",
    "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": "5244 MEMORIAL DRIVE",
            "address_2": "SUITE 1101",
            "city": "STONE MOUNTAIN",
            "state": "GA",
            "postal_code": "300833157",
            "telephone_number": "404-905-0100",
            "fax_number": "877-890-2406"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERWELL SENIOR PRIMARY CARE GA PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTERWELL SENIOR PRIMARY CARE GA PC",
        "enumeration_date": "2021-06-10",
        "last_updated": "2026-08-24",
        "certification_date": "2026-08-24",
        "status": "A",
        "authorized_official_last_name": "MARTINEZ",
        "authorized_official_first_name": "ANGIE",
        "authorized_official_title_or_position": "CREDENTIALING SUPERVISOR",
        "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-Stone Mountain",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "CenterWell Senior Primary Care-Stone Mountain",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Stone Mountain, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 24, 2026; 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.