Healthcare Provider Details

I. General information

NPI: 1508240326
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12101 CAROL LN
FREDERICKSBURG VA
22407-6101
US

IV. Provider business mailing address

12101 CAROL LN
FREDERICKSBURG VA
22407-6101
US

V. Phone/Fax

Practice location:
  • Phone: 540-785-7810
  • Fax: 540-786-3099
Mailing address:
  • Phone: 540-785-7810
  • Fax: 540-786-3099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateVA
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateVA

VIII. Authorized Official

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