Healthcare Provider Details

I. General information

NPI: 1255096442
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3388 PRINCESS ANNE RD STE 2001
VIRGINIA BEACH VA
23456-2612
US

IV. Provider business mailing address

3388 PRINCESS ANNE RD STE 2001
VIRGINIA BEACH VA
23456-2612
US

V. Phone/Fax

Practice location:
  • Phone: 757-507-7270
  • Fax: 757-227-5055
Mailing address:
  • Phone: 757-507-7270
  • Fax: 757-227-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DORIS PRINCE
Title or Position: DIRECTOR
Credential:
Phone: 757-983-5475