NPIMap

Organization Active NPI

Centerwell Senior Primary Care Ms PC

Doing business as CenterWell Senior Primary Care-Jackson West

  • Internal Medicine Physician
  • Jackson, MS
National Provider Identifier
1821864174
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 MS PC
Doing business as
CenterWell Senior Primary Care-Jackson West
Practice address
4890 Highway 18 W
Jackson, MS 39209-9666
Phone
(407) 447-7120
NPI assigned
Nov 28, 2023
Last updated
Jul 3, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
CENTERWELL SENIOR PRIMARY CARE MS 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 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

4890 Highway 18 W
Jackson, MS 39209-9666

Mailing address

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

Other names 1

  • CenterWell Senior Primary Care-Jackson West Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230315000489 MS Part B Supplier - Clinic/Group Practice 0143694190 Receives reassigned benefits from 28 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Jackson, MS; Biloxi, MS; Gulfport, MS

Other NPIs on the same Medicare enrollment 3

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
25D2307662Centerwell Senior Primary Care-Jackson West4890 Highway 18 W Unit a, Jackson, MS 39209Certificate of waiverJul 11, 2028

National Provider Directory

National Provider Directory
Tax ID family
Centerwell Senior Primary5 organizations share this tax ID, including this one
Part of
Centerwell Senior Primary

Other organizations with this tax ID 4

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

Locations

2650 Beach Blvd
Ste 31A
Biloxi, MS 39531
Phone (601) 647-9670

12057 Highway 49
Ste C
Gulfport, MS 39503
Phone (228) 831-1140

4890 Highway 18 W
Jackson, MS 39209
Phone (601) 301-5385

Practitioners & affiliated clinicians

Practitioners 20

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 20

NPI Registry JSON

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

{
    "created_epoch": "1701129600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1719964800000",
    "number": "1821864174",
    "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": "4890 HIGHWAY 18 W",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392099666",
            "telephone_number": "407-447-7120"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERWELL SENIOR PRIMARY CARE MS PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTERWELL SENIOR PRIMARY CARE MS PC",
        "enumeration_date": "2023-11-28",
        "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 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-Jackson West",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "CenterWell Senior Primary Care-Jackson West",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jackson, MS

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.