NPIMap

Organization Active NPI

Centerwell Senior Primary Care VA PLLC

Doing business as CenterWell Senior Primary Care-South Laburnum

  • Internal Medicine Physician
  • Henrico, VA
National Provider Identifier
1821798141
Registry record updated Aug 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
CENTERWELL SENIOR PRIMARY CARE VA PLLC
Doing business as
CenterWell Senior Primary Care-South Laburnum
Practice address
4722 S Laburnum Ave
Henrico, VA 23231-2712
Phone
(804) 604-2430
Fax
(877) 471-2996
NPI assigned
Mar 6, 2023
Last updated
Aug 19, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
CENTERWELL SENIOR PRIMARY CARE VA PLLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 19, 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

4722 S Laburnum Ave
Henrico, VA 23231-2712

Mailing address

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

Other names 2

  • CenterWell Senior Primary Care-South Laburnum Doing business as
  • CenterWell Senior Primary Care VA PC Former legal business name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230523000312 VA Part B Supplier - Clinic/Group Practice 8426414186 Receives reassigned benefits from 46 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Portsmouth, VA; Richmond, VA; Norfolk, VA; Newport News, VA; Henrico, VA; Hampton, VA; Chesapeake, VA

Other NPIs on the same Medicare enrollment 7

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
49D2281921Centerwell Senior Primary Care-South Laburnum4722 S Laburnum Ave, Henrico, VA 23231Certificate of waiverMay 14, 2027

National Provider Directory

National Provider Directory
Tax ID family
Centerwell Senior Primary Care VA PLLC10 organizations share this tax ID, including this one
Part of
Centerwell Senior Primary Care VA PLLC

Other organizations with this tax ID 9

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

Locations

8191 Brook Rd
Ste Mn
Richmond, VA 23227
Phone (804) 596-5320

Practitioners & affiliated clinicians

Practitioners 7

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": "1678060800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724025600000",
    "number": "1821798141",
    "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": "4722 S LABURNUM AVE",
            "city": "HENRICO",
            "state": "VA",
            "postal_code": "232312712",
            "telephone_number": "804-604-2430",
            "fax_number": "877-471-2996"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERWELL SENIOR PRIMARY CARE VA PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTERWELL SENIOR PRIMARY CARE VA PLLC",
        "enumeration_date": "2023-03-06",
        "last_updated": "2024-08-19",
        "certification_date": "2024-08-19",
        "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-South Laburnum",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "CenterWell Senior Primary Care VA PC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Henrico, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 19, 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.