Provider Demographics
NPI:1437331725
Name:SENTARA MEDICAL GROUP
Entity type:Organization
Organization Name:SENTARA MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING 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:757-687-1076
Mailing Address - Street 1:PO BOX 2502
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-2502
Mailing Address - Country:US
Mailing Address - Phone:757-457-5480
Mailing Address - Fax:757-549-4168
Practice Address - Street 1:113 GAINSBOROUGH SQ
Practice Address - Street 2:STE 202
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1713
Practice Address - Country:US
Practice Address - Phone:757-457-5480
Practice Address - Fax:757-549-4168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0597050045Medicare NSC