Healthcare Provider Details

I. General information

NPI: 1164665824
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2009
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SENTARA CIR SUITE 320
WILLIAMSBURG VA
23188-5716
US

IV. Provider business mailing address

400 SENTARA CIR SUITE 320
WILLIAMSBURG VA
23188-5716
US

V. Phone/Fax

Practice location:
  • Phone: 757-345-4700
  • Fax:
Mailing address:
  • Phone: 757-345-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MRS. ARRIE P HINES
Title or Position: MANAGER
Credential:
Phone: 757-252-3339