NPIMap

Organization Active NPI

Centerwell Senior Primary Care NC JV PC

Doing business as CenterWell Senior Primary Care-Montclaire

  • Internal Medicine Physician
  • Charlotte, NC
National Provider Identifier
1942074950
Registry record updated Nov 9, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
CENTERWELL SENIOR PRIMARY CARE NC JV PC
Doing business as
CenterWell Senior Primary Care-Montclaire
Practice address
5415 South Blvd
Charlotte, NC 28217-4119
Phone
(704) 869-0321
Fax
(877) 977-5366
NPI assigned
Nov 9, 2023
Last updated
Nov 9, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
CENTERWELL SENIOR PRIMARY CARE NC JV PCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 9, 2023

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 Physician 207Q00000X NU
Internal Medicine Physician 207R00000X NU Primary
General Practice Physician 208D00000X NU

Addresses

Primary practice location

5415 South Blvd
Charlotte, NC 28217-4119

Mailing address

4700 Millenia Blvd Ste 650
Orlando, FL 32839-6013
Phone (407) 447-7120

Other names 1

  • CenterWell Senior Primary Care-Montclaire Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
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

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
34D2297898Centerwell Senior Primary Care-Montclaire5415 South Blvd, Charlotte, NC 28217Certificate of waiverJan 23, 2028

National Provider Directory

National Provider Directory
Tax ID family
Centerwell Senior Primary Care NC JV PC11 organizations share this tax ID, including this one
Part of
Centerwell Senior Primary Care NC JV PC

Other organizations with this tax ID 10

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

Practitioners & affiliated clinicians

Practitioners 5

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": "1699488000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1699488000000",
    "number": "1942074950",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4700 MILLENIA BLVD STE 650",
            "city": "ORLANDO",
            "state": "FL",
            "postal_code": "328396013",
            "telephone_number": "407-447-7120"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5415 SOUTH BLVD",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282174119",
            "telephone_number": "704-869-0321",
            "fax_number": "877-977-5366"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERWELL SENIOR PRIMARY CARE NC JV PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTERWELL SENIOR PRIMARY CARE NC JV PC",
        "enumeration_date": "2023-11-09",
        "last_updated": "2023-11-09",
        "certification_date": "2023-11-09",
        "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": "",
            "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-Montclaire",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Charlotte, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 9, 2023; 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.