Healthcare Provider Details

I. General information

NPI: 1851538201
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5659 PARKWAY DR STE 230
GLOUCESTER VA
23061-3782
US

IV. Provider business mailing address

5659 PARKWAY DR STE 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 TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DORIS PRINCE
Title or Position: DIRECTOR
Credential:
Phone: 757-983-5475