Healthcare Provider Details

I. General information

NPI: 1487056115
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 KEMPSVILLE RD STE 104
NORFOLK VA
23502-3927
US

IV. Provider business mailing address

844 KEMPSVILLE RD STE 104
NORFOLK VA
23502-3927
US

V. Phone/Fax

Practice location:
  • Phone: 757-261-0041
  • Fax: 757-431-7770
Mailing address:
  • Phone: 757-261-0041
  • Fax: 757-431-7770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateVA

VIII. Authorized Official

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