Provider Demographics
NPI:1891977187
Name:SENTARA MEDICAL GROUP
Entity type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-983-5475
Mailing Address - Street 1:9506 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:NASSAWADOX
Mailing Address - State:VA
Mailing Address - Zip Code:23413
Mailing Address - Country:US
Mailing Address - Phone:757-395-1600
Mailing Address - Fax:757-510-9120
Practice Address - Street 1:9506 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:NASSAWADOX
Practice Address - State:VA
Practice Address - Zip Code:23413-0000
Practice Address - Country:US
Practice Address - Phone:757-395-1600
Practice Address - Fax:757-510-9120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02033OtherMEDICARE GROUP NUMBER