MEDICARE: SENTARA MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C02033	OTHER	VA	MEDICARE GROUP NUMBER

General Provider Information

NPI Number	:	1245577550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENTARA MEDICAL GROUP

Provider Business Mailing Address
First Line	:	2300 OPITZ BLVD
Second Line	:	HEART AND VASCULAR CENTER
City	:	WOODBRIDGE
State	:	VA
Zip	:	22191-3345
Country	:	US
Telephone Number	:	703-680-4254
Fax Number	:	855-210-2385

Provider Business Practice Location Address
First Line	:	2300 OPITZ BLVD
Second Line	:	HEART AND VASCULAR CENTER
City	:	WOODBRIDGE
State	:	VA
Zip	:	22191-3345
Country	:	US
Telephone Number	:	703-680-4254
Fax Number	:	855-210-2385

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. CINDY A TAYLOR
Credential	:
Telephone Number	:	757-252-3344

Provider Enumeration Date	:	01/07/2013
Last Update Date	:	01/07/2013

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Directions to “SENTARA MEDICAL GROUP ” Practice Location

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