Provider Demographics
NPI:1770601189
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 1:400 SENTARA CIRCLE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-5725
Mailing Address - Country:US
Mailing Address - Phone:757-345-4600
Mailing Address - Fax:757-345-4601
Practice Address - Street 1:400 SENTARA CIRCLE
Practice Address - Street 2:SUITE 450
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5725
Practice Address - Country:US
Practice Address - Phone:757-345-4600
Practice Address - Fax:757-345-4601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 207Q00000X
VA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0597050028Medicare NSC