Provider Demographics
NPI:1609103902
Name:SENTARA MEDICAL GROUP
Entity Type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:SENTARA INFECTIOUS DISEASE SPECIALIST
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:757-252-2765
Mailing Address - Street 1:2790 GODWIN BLVD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8151
Mailing Address - Country:US
Mailing Address - Phone:757-934-4550
Mailing Address - Fax:
Practice Address - Street 1:2790 GODWIN BLVD
Practice Address - Street 2:SUITE 225
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8151
Practice Address - Country:US
Practice Address - Phone:757-934-4550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-06
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02033OtherMEDICARE GROUP NUMBER