Provider Demographics
NPI:1982642781
Name:SENTARA MEDICAL GROUP
Entity Type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:FORT NORFOLK DIAGNOSTIC CENTER
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 1:301 RIVERVIEW AVE
Mailing Address - Street 2:SUITE 830
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1065
Mailing Address - Country:US
Mailing Address - Phone:757-252-9100
Mailing Address - Fax:757-510-9297
Practice Address - Street 1:301 RIVERVIEW AVE
Practice Address - Street 2:SUITE 830
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1065
Practice Address - Country:US
Practice Address - Phone:757-252-9100
Practice Address - Fax:757-510-9297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA49D02297892085R0202X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAFVVXU2Medicare PIN