Healthcare Provider Details

I. General information

NPI: 1710318241
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2760 GODWIN BLVD STE 100
SUFFOLK VA
23434-8036
US

IV. Provider business mailing address

2760 GODWIN BLVD STE 100
SUFFOLK VA
23434-8036
US

V. Phone/Fax

Practice location:
  • Phone: 757-983-8650
  • Fax: 757-983-8673
Mailing address:
  • Phone: 757-983-8650
  • Fax: 757-538-9038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MRS. CINDY A TAYLOR
Title or Position: MANAGER
Credential:
Phone: 757-252-2765