NPIMap

Organization Active NPI

Centerwell Senior Primary Care FL JV PLLC

  • Internal Medicine Physician
  • Jacksonville, FL
National Provider Identifier
1861229072
Registry record updated Dec 10, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
CENTERWELL SENIOR PRIMARY CARE FL JV PLLC
Practice address
11900 Atlantic Blvd # 1
Jacksonville, FL 32225-2920
Phone
(048) 391-0379
NPI assigned
Sep 19, 2024
Organization subpart
Yes
Parent organization
CENTERWELL SENIOR PRIMARY CARE FL JV PLLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 10, 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

11900 Atlantic Blvd # 1
Jacksonville, FL 32225-2920

Mailing address

6101 Blue Lagoon Dr Ste 200
Miami, FL 33126-3168
Phone (407) 447-7120

Other names 1

  • Conviva Atlantic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20241008003187 FL Part B Supplier - Clinic/Group Practice 5698206167 Receives reassigned benefits from 34 practitioners
10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Jacksonville, FL; Winter Garden, FL; Wesley Chapel, FL; St Petersburg, FL; Sanford, FL; Orlando, FL; New Port Richey, FL; Hudson, FL

Other NPIs on the same Medicare enrollment 10

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
10D2313691Centerwell Senior Primary Care FL11900 Atlantic Blvd, Jacksonville, FL 32225Certificate of waiverNov 4, 2026

National Provider Directory

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

Other organizations with this tax ID 9

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

Locations

3647 S Orlando Dr
Sanford, FL 32773
Phone (407) 541-0115

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 3

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

NPI Registry JSON

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

{
    "created_epoch": "1726704000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1733788800000",
    "number": "1861229072",
    "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": "407-447-7120",
            "fax_number": "407-770-0661"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11900 ATLANTIC BLVD # 1",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322252920",
            "telephone_number": "048-391-0379"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERWELL SENIOR PRIMARY CARE FL JV PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTERWELL SENIOR PRIMARY CARE FL JV PLLC",
        "enumeration_date": "2024-09-19",
        "last_updated": "2024-12-10",
        "certification_date": "2024-12-10",
        "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": "Conviva Atlantic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Conviva Atlantic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jacksonville, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 10, 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.