NPIMap

Organization Active NPI

Centerwell Senior Primary Care SC JV PC

Doing business as CenterWell Senior Primary Care-Cayce

  • Internal Medicine Physician
  • West Columbia, SC
National Provider Identifier
1962101501
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 SC JV PC
Doing business as
CenterWell Senior Primary Care-Cayce
Practice address
1612 Airport Blvd
West Columbia, SC 29169-5016
Phone
(803) 380-6399
Fax
(877) 484-7187
NPI assigned
Mar 2, 2023
Last updated
Aug 19, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
CENTERWELL SENIOR PRIMARY CARE SC JV PCAs 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 Physician 207Q00000X NU
Internal Medicine Physician 207R00000X NU Primary
General Practice Physician 208D00000X NU

Addresses

Primary practice location

1612 Airport Blvd
West Columbia, SC 29169-5016

Mailing address

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

Other names 1

  • CenterWell Senior Primary Care-Cayce Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230426000585 SC Part B Supplier - Clinic/Group Practice 5294190252 Receives reassigned benefits from 39 practitioners
8 other NPIs on this enrollment
Practice locations: Columbia, SC; West Columbia, SC; North Myrtle Beach, SC; North Augusta, SC; Myrtle Beach, SC; Murrells Inlet, SC

Other NPIs on the same Medicare enrollment 8

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
42D2281289Centerwell Senior Primary Care-Cayce1612 Airport Blvd, West Columbia, SC 29169Certificate of waiverMay 3, 2027

National Provider Directory

National Provider Directory
Tax ID family
Centerwell Senior Primary Care SC JV PC9 organizations share this tax ID, including this one
Part of
Centerwell Senior Primary Care SC JV PC

Other organizations with this tax ID 8

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

Locations

2571 Forest Dr
Columbia, SC 29204
Phone (803) 254-2376

2738 Decker Blvd
Ste A
Columbia, SC 29206
Phone (803) 969-0543

1612 Airport Blvd
West Columbia, SC 29169
Phone (803) 380-6399

Practitioners & affiliated clinicians

Practitioners 40

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 40

NPI Registry JSON

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

{
    "created_epoch": "1677715200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724025600000",
    "number": "1962101501",
    "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": "1612 AIRPORT BLVD",
            "city": "WEST COLUMBIA",
            "state": "SC",
            "postal_code": "291695016",
            "telephone_number": "803-380-6399",
            "fax_number": "877-484-7187"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERWELL SENIOR PRIMARY CARE SC JV PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTERWELL SENIOR PRIMARY CARE SC JV PC",
        "enumeration_date": "2023-03-02",
        "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": "",
            "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-Cayce",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "CenterWell Senior Primary Care-Cayce",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in West Columbia, SC

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.