Healthcare Provider Details

I. General information

NPI: 1023290319
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 02/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6333 CENTER DR BLDG 16
NORFOLK VA
23502-4126
US

IV. Provider business mailing address

PO BOX 2502
NORFOLK VA
23501-2502
US

V. Phone/Fax

Practice location:
  • Phone: 757-457-5100
  • Fax: 757-962-8020
Mailing address:
  • Phone: 757-457-5100
  • Fax: 757-962-8020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: CINDY A TAYLOR
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 757-687-1076