Healthcare Provider Details

I. General information

NPI: 1306171301
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 COLISEUM DR STE 200A
HAMPTON VA
23666-5975
US

IV. Provider business mailing address

4000 COLISEUM DR STE 200A
HAMPTON VA
23666-5975
US

V. Phone/Fax

Practice location:
  • Phone: 757-736-1520
  • Fax: 757-756-5116
Mailing address:
  • Phone: 757-507-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DORIS PRINCE
Title or Position: MANAGER
Credential:
Phone: 757-252-2760