Provider Demographics
NPI:1235319849
Name:SENTARA MEDICAL GROUP
Entity Type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:UROLOGY OF VIRGINIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ARRIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-252-3339
Mailing Address - Street 1:400 W BRAMBLETON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1115
Mailing Address - Country:US
Mailing Address - Phone:757-457-5170
Mailing Address - Fax:757-626-0768
Practice Address - Street 1:400 W BRAMBLETON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1115
Practice Address - Country:US
Practice Address - Phone:757-457-5170
Practice Address - Fax:757-626-0768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0597050064Medicare NSC