Provider Demographics
NPI:1013035435
Name:SENTARA MEDICAL GROUP
Entity Type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:SENTARA FAMILY MEDICINE PHYSICIANS
Other - Org Type:Doing Business As
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 1:109 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23888-2747
Mailing Address - Country:US
Mailing Address - Phone:757-899-3521
Mailing Address - Fax:757-899-7104
Practice Address - Street 1:109 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:VA
Practice Address - Zip Code:23888-2747
Practice Address - Country:US
Practice Address - Phone:757-899-3521
Practice Address - Fax:757-899-7104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0597050055Medicare NSC