Healthcare Provider Details

I. General information

NPI: 1295969962
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5659 PARKWAY DR SUITE 230
GLOUCESTER VA
23061-3782
US

IV. Provider business mailing address

5659 PARKWAY DR SUITE 230
GLOUCESTER VA
23061-3782
US

V. Phone/Fax

Practice location:
  • Phone: 804-210-1055
  • Fax: 804-210-1059
Mailing address:
  • Phone: 804-210-1055
  • Fax: 804-210-1059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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