NPIMap

Organization Active NPI

Centerwell Senior Primary Care Ga PC

Doing business as CenterWell Senior Primary Care-Old National

  • Internal Medicine Physician
  • South Fulton, GA
National Provider Identifier
1801463468
Registry record updated Jul 3, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
CENTERWELL SENIOR PRIMARY CARE GA PC
Doing business as
CenterWell Senior Primary Care-Old National
Practice address
6085 Old National Hwy Ste G
South Fulton, GA 30349-4333
Phone
(470) 754-6360
Fax
(877) 780-7359
NPI assigned
Jun 10, 2021
Last updated
Jul 3, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
CENTERWELL SENIOR PRIMARY CARE GA PCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 3, 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 Specialist
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

6085 Old National Hwy Ste G
South Fulton, GA 30349-4333

Mailing address

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

Other names 1

  • CenterWell Senior Primary Care-Old National Doing business as

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
Practice locations: Atlanta, GA; Woodstock, GA; Suwanee, GA; Stone Mountain, GA; South Fulton, GA; Savannah, GA; Morrow, GA; Marietta, GA…

Other NPIs on the same Medicare enrollment 12

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
11D2241944Centerwell Senior Primary Care - Old National6085 Old Nationl Highway, Suite G, Atlanta, GA 30349Certificate of waiverNov 2, 2027

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.

Practitioners & affiliated clinicians

Practitioners 102

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 102

NPI Registry JSON

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

{
    "created_epoch": "1623283200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1719964800000",
    "number": "1801463468",
    "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": "6085 OLD NATIONAL HWY STE G",
            "city": "SOUTH FULTON",
            "state": "GA",
            "postal_code": "303494333",
            "telephone_number": "470-754-6360",
            "fax_number": "877-780-7359"
        }
    ],
    "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": "2024-07-03",
        "certification_date": "2024-07-03",
        "status": "A",
        "authorized_official_last_name": "MARTINEZ",
        "authorized_official_first_name": "ANGIE",
        "authorized_official_title_or_position": "SENIOR CREDENTIALING SPECIALIST",
        "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-Old National",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in South Fulton, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 3, 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.