Healthcare Provider Details

I. General information

NPI: 1083073464
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 BRIDGE RD STE 202
SUFFOLK VA
23435-1117
US

IV. Provider business mailing address

3920 BRIDGE RD STE 202
SUFFOLK VA
23435-1117
US

V. Phone/Fax

Practice location:
  • Phone: 757-395-1600
  • Fax: 757-510-9136
Mailing address:
  • Phone: 757-395-1600
  • Fax: 757-510-9136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateVA

VIII. Authorized Official

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