Healthcare Provider Details

I. General information

NPI: 1639357239
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4374 NEW TOWN AVE SUITE 104
WILLIAMSBURG VA
23188-2865
US

IV. Provider business mailing address

4374 NEW TOWN AVE SUITE 104
WILLIAMSBURG VA
23188-2865
US

V. Phone/Fax

Practice location:
  • Phone: 757-259-1335
  • Fax: 757-259-1395
Mailing address:
  • Phone: 757-259-1335
  • Fax: 757-259-1395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number49D1080933
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

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