Healthcare Provider Details

I. General information

NPI: 1447510763
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 04/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2790 GODWIN BLVD STE 100
SUFFOLK VA
23434-8151
US

IV. Provider business mailing address

2790 GODWIN BLVD STE 100
SUFFOLK VA
23434-8151
US

V. Phone/Fax

Practice location:
  • Phone: 757-983-8750
  • Fax: 757-510-9442
Mailing address:
  • Phone: 757-983-8750
  • Fax: 757-510-9442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

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