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	332B00000X	Durable Medical Equipment & Medical Supplies		VA
2	207R00000X	Internal Medicine Physician		VA

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	:	1932583010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENTARA MEDICAL GROUP

Provider Business Mailing Address
First Line	:	4900 PLANK RD
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22407-6626
Country	:	US
Telephone Number	:	540-785-7810
Fax Number	:	540-785-7741

Provider Business Practice Location Address
First Line	:	4900 PLANK RD
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22407-6626
Country	:	US
Telephone Number	:	540-785-7810
Fax Number	:	540-785-7741

Authorized Official
Title or Position	:	MANAGER
Name	:	CINDY A TAYLOR
Credential	:
Telephone Number	:	757-252-2765

Provider Enumeration Date	:	07/17/2015
Last Update Date	:	07/17/2015

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