1093806143 NPI number — SENTARA MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093806143 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:
SENTARA FAMILY MEDICINE PHYSICIANS
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:
1093806143
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2022
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:
STE 200
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:
757-395-6630
Provider Business Mailing Address Fax Number:
757-507-9074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1080 FIRST COLONIAL RD
Provider Second Line Business Practice Location Address:
STE 200
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:
757-395-6630
Provider Business Practice Location Address Fax Number:
757-507-9074
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PRINCE
Authorized Official First Name:
DORIS
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
757-983-5475

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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