Healthcare Provider Details

I. General information

NPI: 1104944529
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4374 NEW TOWN AVE STE 102
WILLIAMSBURG VA
23188-2688
US

IV. Provider business mailing address

4374 NEW TOWN AVE STE 102
WILLIAMSBURG VA
23188-2688
US

V. Phone/Fax

Practice location:
  • Phone: 757-984-6170
  • Fax: 757-259-6794
Mailing address:
  • Phone: 757-984-6170
  • Fax: 757-259-6794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CINDY A TAYLOR
Title or Position: MANAGER
Credential:
Phone: 757-252-2765