Provider Demographics
NPI:1942684097
Name:SENTARA MEDICAL GROUP
Entity Type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:SENTARA PRATT MEDICAL GROUP
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 1:7967 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:KING GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:22485-7075
Mailing Address - Country:US
Mailing Address - Phone:540-775-6445
Mailing Address - Fax:540-775-6449
Practice Address - Street 1:7967 KINGS HWY
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-7075
Practice Address - Country:US
Practice Address - Phone:540-775-6445
Practice Address - Fax:540-775-6449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02033OtherMEDICARE GROUP NUMBER