Provider Demographics
NPI:1962615211
Name:SENTARA MEDICAL GROUP
Entity type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-252-3344
Mailing Address - Street 1:1080 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 412
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2406
Mailing Address - Country:US
Mailing Address - Phone:757-395-6500
Mailing Address - Fax:757-275-9885
Practice Address - Street 1:1080 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 412
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2406
Practice Address - Country:US
Practice Address - Phone:757-395-6500
Practice Address - Fax:757-275-9885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02033OtherMEDICARE GROUP NUMBER