Provider Demographics
NPI:1841692571
Name:SENTARA MEDICAL GROUP
Entity type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-983-5475
Mailing Address - Street 1:1080 FIRST COLONIAL RD STE 305
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2406
Mailing Address - Country:US
Mailing Address - Phone:757-395-1880
Mailing Address - Fax:757-431-7770
Practice Address - Street 1:1080 FIRST COLONIAL RD STE 305
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2406
Practice Address - Country:US
Practice Address - Phone:757-395-1880
Practice Address - Fax:757-431-7770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X, 213ES0131X
VA332B00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02033OtherMEDICARE GROUP NUMBER