Provider Demographics
NPI:1649530965
Name:SENTARA MEDICAL GROUP
Entity type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:4001 COLISEUM DR
Mailing Address - Street 2:STE 310
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6257
Mailing Address - Country:US
Mailing Address - Phone:757-827-2115
Mailing Address - Fax:757-510-9383
Practice Address - Street 1:4001 COLISEUM DR
Practice Address - Street 2:STE 310
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6257
Practice Address - Country:US
Practice Address - Phone:757-827-2115
Practice Address - Fax:757-510-9383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02033OtherMEDICARE GROUP NUMBER