Healthcare Provider Details

I. General information

NPI: 1922677897
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 06/23/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR STE 8630A
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

600 GRESHAM DR STE 8630A
NORFOLK VA
23507-1904
US

V. Phone/Fax

Practice location:
  • Phone: 757-388-6144
  • Fax: 757-388-8749
Mailing address:
  • Phone: 757-388-6144
  • Fax: 757-388-8749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

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