Healthcare Provider Details

I. General information

NPI: 1710304027
Provider Name (Legal Business Name): SENTARA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 OPITZ BLVD STE 110
WOODBRIDGE VA
22191-3362
US

IV. Provider business mailing address

2280 OPITZ BLVD STE 110
WOODBRIDGE VA
22191-3362
US

V. Phone/Fax

Practice location:
  • Phone: 35-238-8807
  • Fax: 757-648-1954
Mailing address:
  • Phone: 703-523-8880
  • Fax: 855-462-1102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DORIS PRINCE
Title or Position: MANAGER
Credential:
Phone: 757-252-2760