Healthcare Provider Details

I. General information

NPI: 1073763389
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 RIVERVIEW AVE STE 202A
NORFOLK VA
23510-1065
US

IV. Provider business mailing address

301 RIVERVIEW AVE STE 202A
NORFOLK VA
23510-1065
US

V. Phone/Fax

Practice location:
  • Phone: 757-252-9015
  • Fax: 757-388-6106
Mailing address:
  • Phone: 757-252-9015
  • Fax: 757-388-6106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery 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