Healthcare Provider Details

I. General information

NPI: 1851699227
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1936 OPITZ BLVD STE A
WOODBRIDGE VA
22191-3360
US

IV. Provider business mailing address

1936 OPITZ BLVD STE A
WOODBRIDGE VA
22191-3360
US

V. Phone/Fax

Practice location:
  • Phone: 703-491-7744
  • Fax: 703-492-1046
Mailing address:
  • Phone: 703-491-7744
  • Fax: 703-492-1046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

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