Healthcare Provider Details

I. General information

NPI: 1568918480
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2790 GODWIN BLVD STE 355
SUFFOLK VA
23434-8151
US

IV. Provider business mailing address

2790 GODWIN BLVD STE 355
SUFFOLK VA
23434-8151
US

V. Phone/Fax

Practice location:
  • Phone: 757-983-8520
  • Fax: 757-579-8643
Mailing address:
  • Phone: 757-983-8520
  • Fax: 757-579-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateVA

VIII. Authorized Official

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