Basic Information
| Provider Information | |||||||||
| NPI: | 1538712724 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTERWELL SENIOR PRIMARY CARE (MO) PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTERWELL SENIOR PRIMARY CARE -GRANDVIEW | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 MILLENIA BLVD STE 650 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328396013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074477120 | ||||||||
| FaxNumber: | 4077700661 | ||||||||
| Practice Location | |||||||||
| Address1: | 1513 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GRANDVIEW | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640302515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167311890 | ||||||||
| FaxNumber: | 8339961159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2019 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | SAVAGE-JETER | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
| AuthorizedOfficialMiddleName: | LACHE' | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8642164620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTERWELL SENIOR PRIMARY CARE (MO) PC | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.