Healthcare Provider Details

I. General information

NPI: 1104043264
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 CARATOKE HWY
MOYOCK NC
27958-8740
US

IV. Provider business mailing address

534 CARATOKE HWY
MOYOCK NC
27958-8740
US

V. Phone/Fax

Practice location:
  • Phone: 252-435-6621
  • Fax: 252-435-2685
Mailing address:
  • Phone: 252-435-6621
  • Fax: 252-435-2685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CINDY A TAYLOR
Title or Position: MANAGER
Credential:
Phone: 757-252-3344