Provider Demographics
NPI:1043602360
Name:SENTARA MEDICAL GROUP
Entity Type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:SENTARA FAMILY & INTERNAL MEDICINE PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-252-2765
Mailing Address - Street 1:701 LUKE ST
Mailing Address - Street 2:STE D
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-9643
Mailing Address - Country:US
Mailing Address - Phone:252-337-9170
Mailing Address - Fax:844-696-5375
Practice Address - Street 1:701 LUKE ST
Practice Address - Street 2:STE D
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-9643
Practice Address - Country:US
Practice Address - Phone:252-337-9170
Practice Address - Fax:844-696-5375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X, 207R00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC232011OtherMEDICARE GROUP NUMBER