Healthcare Provider Details

I. General information

NPI: 1043602360
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2015
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 LUKE ST STE D
EDENTON NC
27932-9643
US

IV. Provider business mailing address

701 LUKE ST STE D
EDENTON NC
27932-9643
US

V. Phone/Fax

Practice location:
  • Phone: 252-337-9170
  • Fax: 844-696-5375
Mailing address:
  • Phone: 252-337-9170
  • Fax: 844-696-5375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNC

VIII. Authorized Official

Name: CINDY A TAYLOR
Title or Position: MANAGER
Credential:
Phone: 757-252-2765