Provider Demographics
NPI:1689958860
Name:SENTARA MEDICAL GROUP
Entity Type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:SENTARA SURGERY SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-983-5475
Mailing Address - Street 1:95 DUNN DR STE 123
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-1503
Mailing Address - Country:US
Mailing Address - Phone:703-523-9550
Mailing Address - Fax:540-699-2584
Practice Address - Street 1:95 DUNN DR STE 123
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-1503
Practice Address - Country:US
Practice Address - Phone:703-523-9550
Practice Address - Fax:540-699-2584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02033OtherMEDICARE GROUP NUMBER