Provider Demographics
NPI:1245577550
Name:SENTARA MEDICAL GROUP
Entity Type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:POTOMAC VASCULAR SURGERY
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 1:2300 OPITZ BLVD
Mailing Address - Street 2:HEART AND VASCULAR CENTER
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3345
Mailing Address - Country:US
Mailing Address - Phone:703-680-4254
Mailing Address - Fax:855-210-2385
Practice Address - Street 1:2300 OPITZ BLVD
Practice Address - Street 2:HEART AND VASCULAR CENTER
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3345
Practice Address - Country:US
Practice Address - Phone:703-680-4254
Practice Address - Fax:855-210-2385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02033OtherMEDICARE GROUP NUMBER