1053350322 NPI number — SENTARA MEDICAL GROUP

Table of content: (NPI 1053350322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053350322 NPI number — SENTARA MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SENTARA MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FIRST COLONIAL DIAGNOSTIC CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053350322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1080 FIRST COLONIAL RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23454-2406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-395-6464
Provider Business Mailing Address Fax Number:
757-395-6490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1080 FIRST COLONIAL RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23454-2406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-395-6464
Provider Business Practice Location Address Fax Number:
757-395-6490
Provider Enumeration Date:
06/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
CINDY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
757-252-3344

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 291U00000X , with the licence number: 49D0981411 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00393284 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com