Healthcare Provider Details

I. General information

NPI: 1811533375
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 FIRST COLONIAL RD STE 300
VIRGINIA BEACH VA
23454-2409
US

IV. Provider business mailing address

1101 FIRST COLONIAL RD STE 300
VIRGINIA BEACH VA
23454-2409
US

V. Phone/Fax

Practice location:
  • Phone: 757-395-1760
  • Fax: 757-756-5148
Mailing address:
  • Phone: 757-395-1760
  • Fax: 757-756-5148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DORIS PRINCE
Title or Position: DIRECTOR
Credential:
Phone: 757-252-2760