Centerwell Senior Primary Care NC JV PC
Organization Active NPI Internal Medicine Physician · Charlotte, NC
NPI 1831836758 · NPPES record last updated Jan 9, 2023
Key facts
- NPI
- 1831836758
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Internal Medicine Physician 207R00000X
- Legal business name
- CENTERWELL SENIOR PRIMARY CARE NC JV PC
- Practice address
- 3512 Wilkinson Blvd Ste 130
Charlotte, NC 28208-5698 - Phone
- (980) 999-2964
- Fax
- (877) 691-5325
- NPI assigned
- May 13, 2022
- Organization subpart
- Yes
- Parent organization (as reported)
- CENTERWELL SENIOR PRIMARY CARE NC JV PC
Authorized official
- Name
- Angie Martinez
- Title
- Senior Credentialing Professional
- Phone
- (407) 447-7120
Other NPIs on the same Medicare enrollment 16
Corporate family (same tax ID) 10
Practitioners 27
-
Jaicie N Congress, FNP-C
-
Margaret O Erhabor, APRN
-
Paula Perry Hampton, FNP
-
Amy Beth Raz, M.D.
-
Jocelyn Alisa Sampson, LCSW
-
Regi Jose Vadassery, M.D.
-
Robert Bruce Hanlin, M.D.
-
Nazik Al-Hashimi, MD
-
Jerell Diego Chua, MPH, D.O.
-
Dorrie Edgeston-Jones, DNP, FNP
-
Latoya Denise Fulton, D.O.
-
Jalecia Maria Jones, FNP-BC
-
Christel N Keisler, M.D.
-
Miesha Kindell, ARNP
-
Kavithamani Mallan, FNP
-
Elie Osta, MD
-
Kusum Paudel, NP
-
Dana Aubrey Preston, PA-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 34D2264859 | Centerwell Senior Primary Care-Wilkinson | Certificate of waiver | Jul 19, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in NC
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20171016002152 | NC | Part B Supplier - Clinic/Group Practice | 2264708486 |
Receives reassigned benefits from 65 practitioners 6 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Burlington, NC; Gastonia, NC; Greensboro, NC; Winston Salem, NC |
| O20230315000375 | NC | Part B Supplier - Clinic/Group Practice | 0345614384 |
Receives reassigned benefits from 59 practitioners 12 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Charlotte, NC; Raleigh, NC; Durham, NC; Asheville, NC |
National Provider Directory
- Tax ID family
- Centerwell Senior Primary Care NC JV PC
- Part of
- Centerwell Senior Primary Care NC PC
Locations
105 River Hills Rd
Ste A
Asheville, NC 28805
Phone (828) 998-1779
4201 University Dr
Ste 101
Durham, NC 27707
Phone (984) 283-1722
2910 E Franklin Blvd
Ste 1
Gastonia, NC 28056
Phone (704) 648-0460
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
3512 Wilkinson Blvd Ste 130
Charlotte, NC 28208-5698
Mailing address
4700 Millenia Blvd Ste 650
Orlando, FL 32839-6013
Phone (407) 447-7120
Other names
- CenterWell Senior Primary Care- Wilkinson
- CenterWell Senior Primary Care NC PC
Other providers in Charlotte, NC
- Centerwell Certified Healthcare Corp.
- Centerwell Senior Primary Care (NC) JV, P.C.
- Centerwell Senior Primary Care (NC) JV, P.C.
- Centerwell Senior Primary Care NC JV PC
- Centerwell Senior Primary Care NC JV PC
- Centerwell Senior Primary Care NC JV PC
- Centerwell Senior Primary Care NC JV PC
- Central Carolina Medical Clinic, P.a.
- Central Carolina Medical Clinic, PA
- Central Pediatrics & Internal Medicine, PA
All providers in Charlotte, NC · Internal Medicine Physician in North Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 9, 2023. 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.