Healthcare Provider Details

I. General information

NPI: 1275747354
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 GLENN MITCHELL DR SUITE 310
VIRGINIA BEACH VA
23456
US

IV. Provider business mailing address

1950 GLENN MITCHELL DR SUITE 310
VIRGINIA BEACH VA
23456
US

V. Phone/Fax

Practice location:
  • Phone: 757-507-0340
  • Fax: 757-507-0341
Mailing address:
  • Phone: 757-507-0340
  • Fax: 757-507-0341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CINDY A TAYLOR
Title or Position: MANAGER
Credential:
Phone: 757-252-3344