Healthcare Provider Details

I. General information

NPI: 1275817058
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 MAPLEDALE PLZ
WOODBRIDGE VA
22193-4535
US

IV. Provider business mailing address

5800 MAPLEDALE PLZ
WOODBRIDGE VA
22193-4535
US

V. Phone/Fax

Practice location:
  • Phone: 703-670-0067
  • Fax: 703-670-0301
Mailing address:
  • Phone: 703-670-0067
  • Fax: 703-670-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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