NPI |
1104449560 |
|
Entity Type Code |
2 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Employer Identification Number EIN |
|
The last name of the provider. If the provider is an individual, this is the legal name. |
Provider Organization Name Legal Business Name |
CENTERWELL SENIOR PRIMARY CARE (NV) PC |
The first name of the provider, if the provider
is an individual. |
Provider Other Organization Name |
PARTNERS IN PRIMARY CARE (NV) PC |
Other name by which the organization provider is or has been known. |
Provider Other Organization Name Type Code |
4 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
Provider First Line Business Practice Location Address |
4700 MILLENIA BLVD STE 650 |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address City Name |
ORLANDO |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
FL |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
328396013 |
The telephone number associated with the location address of the provider being identified. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The date the provider was assigned a unique identifier (assigned an NPI). |
Provider Business Practice Location Address Telephone Number |
4074477120 |
The date that a record was last updated or changed. |
Provider Business Practice Location Address Fax Number |
4077700661 |
The code designating the provider’s gender if the provider is a person. |
Provider Enumeration Date |
5/20/2020 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Last Update Date |
2/15/2024 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Authorized Official Last Name |
MARTINEZ |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Authorized Official First Name |
ANGIE |
|
Authorized Official Title or Position |
SENIOR CREDENTIALING PROFESSIONAL |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
Authorized Official Telephone Number |
4074477120 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
208D00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
N |
|
Healthcare Provider Taxonomy Code 2 |
207RI0011X |
|
Healthcare Provider Primary Taxonomy Switch 2 |
N |
|
Healthcare Provider Taxonomy Code 3 |
207Q00000X |
|
Healthcare Provider Primary Taxonomy Switch 3 |
N |
|
Healthcare Provider Taxonomy Code 4 |
207R00000X |
|
Healthcare Provider Primary Taxonomy Switch 4 |
Y |
|
Is Organization Subpart |
Y |
|
Parent Organization LBN |
CENTERWELL SENIOR PRIMARY CARE (NV) PC |
|
Parent Organization TIN |
|
|
Healthcare Provider Taxonomy Group 1 |
193200000X MULTI-SPECIALTY GROUP |
|
Healthcare Provider Taxonomy Group 2 |
193200000X MULTI-SPECIALTY GROUP |
|
Healthcare Provider Taxonomy Group 3 |
193200000X MULTI-SPECIALTY GROUP |
|
Healthcare Provider Taxonomy Group 4 |
193200000X MULTI-SPECIALTY GROUP |
|
NPI Certification Date |
2/15/2024 |
|